Chapter 45.

Pastc and Reconstructve Surgery

Monday, October 11, 2010
1:56 PM
Key Points
1. Pastc surgery s the ed of surgery that addresses congenta and acqured
defects, strvng to return form and functon.
2. Chdren dagnosed wth ceft and cranofaca anomaes benet from
nterdscpnary care at a specazed center focusng on team care. Long-term
foow-up durng growth and deveopment s crtca for optma outcomes.
3. Reconstructve surgery attempts to restore form and functon through
technques that ncude skn graftng, use of musce aps, bone graftng, tssue
expanson, free tssue transfer wth mcrosurgery, and repantaton.
4. Aesthetc surgery s surgery performed to reshape the norma structure of the
body to mprove the patent's appearance and sef-esteem. Patents undergong
aesthetc surgery present a unque chaenge. The most mportant outcome
parameter s patent satsfacton, and therefore a thorough understandng of the
patent's motvatons, goas, and expectatons s crtca.
5. Pastc surgery has been a ed of nnovaton. The future of the specaty key
ncudes advancements n the areas of regeneratve medcne, feta surgery, and
reconstructve transpantaton wth composte tssue aotranspants.

Historical Background
The ed of pastc surgery focuses on the restoraton of form and functon to those
who have congenta and acqured deformtes. Pastc surgery routney addresses
new probems and chaenges; therefore, the pastc surgeon must have an expert
knowedge of anatomy and surgca technque to address new chaenges.

The word plastic s derved from the Greek plastikos, meanng "to mod." Athough
the term plastic surgery can be found n severa medca wrtngs from the
eghteenth and nneteenth centures, t was |ohn Stage Davs who estabshed the
name of the specaty wth the 1919 pubcaton of hs book Plastic SurgeryIts
Principles and Practice.

Certany, for centures pastc surgery operatons have been performed. One of the
earest accounts of reconstructve surgery can be found n the Sushruta Samhita,
an eary text from the sxth or seventh century B.C. by the practtoner Sushruta. In
ths wrtng, the reconstructon of an amputated nose wth a pedced forehead ap
and the reconstructon of the ear wth cheek aps was descrbed. In addton, n the
rst century A.D., the Roman physcans Auus Corneus Cesus and Pauus
Aegneta descrbed operatons for traumatc n|ures of the face.

The rst textbook of pastc surgery s beeved to be Gaspara Tagacozz's 1597
pubcaton De Curtorum Chirurgia per Insitionem. Ths text descrbes the
reconstructon of the nose wth a pedced arm ap. The nneteenth century saw
advances n reconstructve surgery, ncudng Guseppe Barono's successfu
graftng of sheepskn. The technques for perfectng human skn graftng foowed
n the ater part of the century.

Great advances n pastc surgery occurred as a resut of the rst and second word
wars. Out of the eds of denta surgery, otoaryngoogy, ophthamoogy, and
genera surgery, the dscpne of pastc surgery was estabshed. The founders of
the ed ncude Sr Harod Ges, an otoaryngoogst, who estabshed a center for
the treatment of maxofaca n|ures n Engand; V. H. Kazan|an, a denta surgeon
from Boston, who estabshed a center n France for the treatment of faca n|ures
ncurred n Word War II; and Vray P. Bar, from St. Lous, who estabshed centers
for the treatment of soft tssue and maxofaca reconstructon for the U.S. Army.
Wth the onset of Word War II, centers of exceence for hand reconstructon
appeared as we.

In the ast 50 years, advances n the ed of pastc surgery have ncuded the
transpantaton of both autoogous and aogenec tssue, tssue expanson,
technques of movng tssues regonay wthn the body as musce and
myocutaneous aps, the dstant transfer of free aps usng mcrosurgery,
repantaton of traumatcay amputated extremtes and dgts, and the emergence
of the ed of cranofaca surgery. The future of pastc surgery w key see
further advances n the reams of regeneratve medcne, feta surgery, and
reconstructve transpantaton wth composte tssue aotranspants.

General Principles
Skin Incisions
Human skn exsts n a state of tenson created by nterna and externa factors.
Externay, skn and underyng subcutaneous tssue are acted on by gravty and
cothng. Internay, skn s sub|ected to forces generated by underyng musces,
|ont extenson and exon, and tetherng of brous tssues from zones of
adherence. As a resut, when skn s ncsed neary t gapes to varabe degrees.
When a crcuar skn excson s performed, the skn defect assumes an eptca
conguraton paraeng the nes of greatest tenson. Car Langer, an anatomst
from Venna, rst fuy descrbed these tenson nes n the md-1800s based on hs
studes of fresh cadavers.1 A. F. Borges descrbed another set of skn nes that,
dherent from Langer's nes, reect the vectors of reaxed skn tenson.2 Athough
the term Langer's lines often s used nterchangeaby wth the term relaxed skin
tension lines, the former nes descrbe skn tenson vectors observed n the
stretched ntegument of cadavers exhbtng rgor morts, whereas the atter nes
ay perpendcuar to and more accuratey reect the acton of underyng musce.2
Krass's nes, whch run aong natura wrnkes and skn creases, tend aso to
foow the reaxed skn tenson nes (Fg. 45-1). Reaxed skn tenson nes may be
expoted to create ncsons and reconstructons that mnmze anatomc dstorton
and mprove cosmess. In areas of anatomc mobty, such as the neck or over
|onts, ncsons are orented ess for aesthetc reasons and more wth the goa of
avodng scar contractures and subsequent functona compromse. In genera,
ncsons are paced perpendcuar to the acton of the |ont.
Fg. 45-1.

Reaxed skn tenson nes.
(Reprnted wth permsson from Whem
et a.1)

There are stuatons, however, n whch the drecton of the ncson has been pre-
estabshed, as n acute aceratons, burns, or od contracted and dstortng scars.
In these crcumstances the prncpes of proper ncson pacement can be
combned wth smpe surgca technques to reorent the scar and essen the
deformty. The Z-pasty technque uses the transposton of random skn aps both
to break up a near scar and to reease a scar contracture through engthenng
(Fg. 45-2; Tabe 45-1).
Fg. 45-2.

Schematc of the Z-pasty technque. Top: Smpe Z-pasty. iddle: Four-ap Z-
pasty. !ottom: Fve-ap Z-pasty.
(Moded wth permsson from Hudson DA: Some thoughts on choosng a Z-pasty:
The Z made smpe. Plast "econstr Surg 106:665, 2000.)

Table 45-1 Tissue Lengtening !it "-Plasty

Type o# "-Plasty Increase in Lengt o# $entral
Li%b &'(
Smpe 45-degree 50
Smpe 60-degree 75
Smpe 90-degree 100
Four-ap wth 60-degree
anges
150
Doube-opposng 75
Fve-ap 125
Source: Moded wth permsson from Hudson DA: Some thoughts on choosng a Z-
pasty: The Z made smpe. Plast "econstr Surg 106:665, 2000.

W-pasty s the technque of scar excson and reconstructon n zgzag fashon to
camouage the resutng scar. In areas where pressure or shearng forces are
expected, as n weghtbearng areas, ncson pannng shoud be performed
carefuy to mnmze the ehect of antagonstc forces on the heang ncson. Ths
pont s dscussed further n "Pressure Sore Treatment."

)ound Healing
The fundamentas of pastc surgery are based on wound-heang physoogy.
Wound repar conssts of an exqustey reguated symphony of moecuar and
ceuar nstruments that act n concert to restore the oca tssue envronment to
prewound condtons. Metaboc mbaances n the wound meu drve ths
orchestraton and contnue to drect t unt heang resoves the mechanca and
metaboc probems. Athough a detaed revew of wound physoogy s presented
esewhere n ths text, t s usefu to emphasze severa ponts.

Tssue n|ury, be t mechanca or metaboc, profoundy and nstanty dsrupts the
tssue mcroenvronment and sets nto moton a cascade of events that combne to
re-estabsh the envronmenta status quo. Dsrupted bood vesses the wound
space wth red bood ces and pasma. In|ured ces reease factor III
(thrombopastn), whch acceerates the cottng cascade. Cottng factors n the
pasma are actvated, and the coaguaton cascade forms thrombn and eventuay
brn. Smutaneousy, the compement system actvates and produces
chemoattractve compement proten fragments. Pateets, actvated by thrombn
and exposed coagen, reease a number of growth factors and cytoknes.
Traumatzed vesses contract n response to both drect physca stmuaton
(medated by the autonomc nervous system) and prostagandns reeased by
pateets. Intact oca mcrovascuature vasodates and eaks pasma n response to
nammatory medators such as hstamne, knns, and serotonn. These eary
events, and others, estabsh hemostass and nammaton.3

Pateet actvaton ntates the rst ma|or escaaton n the nammatory response.
Wthn mnutes pateets reease a number of sgnang moecues from ther
-granues to attract macrophages, poymorphonucear ces (PMNs), brobasts, and
vascuar endothea ces. Wthn a few hours of n|ury, PMNs and macrophages
nvade the wound space and begn to remove tssue debrs, coaguaton protens,
and bactera. Athough both PMNs and macrophages begn to margnate eary,
PMNs domnate durng the rst few days. PMNs aso consttute the prmary defense
aganst nvadng organsms that have breached the epthea barrer. PMNs and
macrophages, n concert wth the compement system, form the bass of "natura"
or "nonspecc" mmunty. If there s no nfecton or foregn matera, the neutroph
popuaton qucky dmnshes by the second day, whereas macrophages contnue
to amass.3

Macrophages become the ma|or popuaton by the thrd day after n|ury. These ces
then domnate the wound regon for days to weeks. Macrophages are thought to be
the "mastermnds" behnd the compcated and ney tuned array of repar events
that characterzes the proferatve phase of heang. Lke neutrophs, actvated
macrophages contnue the task of wound dbrdement. They are a rch source of
degradatve enzymes that process the extraceuar matrx to make room for
remodeng. Tghty coordnated reease of the many growth factors, coony-
stmuatng factors, ntereukns, nterferons, and cytoknes gves the macrophage
the abty to reguate mgraton, proferaton, and specc proten synthess of
mutpe ce nes. Macrophages ead the characterstc processon of new tssue
nto the wound dead space. Immature, repcatng brobasts foow the
macrophages. Mature brobasts then advance nto the wound space and are, n
turn, foowed by newy formng capary buds, the ast ces n the processon.3

As prevousy mentoned, n|ury perturbs the mcroenvronment and eads to the
autoampfyng nammatory phase. As a resut of these processes, three changes
occur n the wound: the envronment becomes hypoxc, acdotc, and
hyperactated. There s at east one bochemca pathway by whch ths ow redox
potenta state can sgna ces to take boogc acton-the adenosne
dphosphorbose (ADPR) system. Speccay, recent evdence has shown that
ateratons of the poyADPR system ahect reguaton of coagen and vascuar
endothea growth factor (VEGF) transcrpton.3 Thus, the metaboc state that s
so deranged n the wound mcroenvronment s ntmatey nked to atered ceuar
functon, whch eads to reparatve ce phenotypes.

After nammaton has begun, brobasts are attracted by many stmu and then
proferate and mgrate nto the ste of n|ury. Fbrobasts are the ma|or producers of
coagen n the repar response. Substances that ncrease coagen deposton and
maturaton ncude actate, oxygen, and growth factors. Lack of these agents and
sterod treatments decrease coagen n wounds.

Macrophages aso usher aong angogeness, argey through the reease of VEGF.
VEGF producton s upreguated by the same wound metaboc envronment that
stmuates coagen producton. Aso ke coagen synthess, VEGF reease s
ncreased by hyperoxa. As neovascuarzaton takes pace, many of the condtons
that sgnaed the start of the nammatory and proferatve phases are resoved,
and the wound-heang response recedes.

Epderma ces are attracted to the heang wound by the same cytoknes that
attract other wound ces. Eptheazaton proceeds best n a most envronment
wth hgh oxygen tenson.3

Preoperatve, ntraoperatve, and postoperatve nterventons may be taken by the
surgeon to mnmze nfecton and optmze wound heang (Tabes 45-2, 45-3, and
45-4). These measures a draw on what we understand of the physoogc wound-
heang process.

Table 45-* Preoperati+e ,anage%ent

Assess and optmze cardopumonary functon; correct hypertenson.
Treat vasoconstrcton: attend to bood voume, thermoreguatory vasoconstrcton,
pan, and anxety.
Assess recent nutrton and provde treatment as approprate.
Treat exstng nfecton.
Assess wound rsk usng the SENIC ndex.
Start admnstraton of vtamn A n patents takng gucocortcods.
Mantan tght bood gucose contro.
SENIC = Study on the Emcacy of Nosocoma Infecton Contro.
Source: Moded wth permsson from Hunt TK, Hopf HW: Wound heang and wound
nfecton: What surgeons and anesthesoogsts can do. Surg Clin #orth $m 77:587,
1997. Copyrght Esever.

Table 45-- Intraoperati+e ,anage%ent

Admnster approprate prophyactc antbotcs at start of procedure. Keep
antbotc eves hgh durng ong operatons.
Keep patent warm.
Mantan gente surgca technque wth mnma use of tes and cautery.
Keep wounds most.
Perform rrgaton n cases of contamnaton.
Eevate tssue oxygen tenson by ncreasng the eve of nspred oxygen.
Deay cosure of heavy contamnated wounds.
Use approprate sutures (and skn tapes).
Use approprate dressngs.
Source: Moded wth permsson from Hunt TK, Hopf HW: Wound heang and wound
nfecton: What surgeons and anesthesoogsts can do. Surg Clin #orth $m 77:587,
1997. Copyrght Esever.

Table 45-4 Postoperati+e ,anage%ent

Keep patent warm.
Provde anagesa to keep patent comfortabe, f not pan free.
Keep up wth thrd-space osses. Remember that fever
ncreases ud osses.
Assess perfuson and react to abnormates.
Avod duress unt pan s gone and patent s warm.
Assess osses (ncudng therma osses) f wound s open.
Assess need for parentera/entera nutrton and respond.
Contnue to contro hypertenson and hypergycema.
Source: Moded wth permsson from Hunt TK, Hopf HW: Wound heang and wound
nfecton: What surgeons and anesthesoogsts can do. Surg Clin #orth $m 77:587,
1997. Copyrght Esever.

Skin Gra#ts and Skin Substitutes
Dscusson of skn graftng requres a basc revew of skn anatomy. Skn s
comprsed of 5% epderms and 95% derms. The derms contans sebaceous
gands, whereas sweat gands and har foces are ocated n the subcutaneous
tssue. The derma thckness and concentraton of skn appendages vary wdey
from one ocaton to another on the body. The skn vascuature s superca to the
superca fasca system and paraes the skn surface. The cutaneous vesses
branch at rght anges to penetrate subcutaneous tssue and arborze n the
derms, nay formng capary tufts between derma papae.4

Skn graftng dates back >3000 years to Inda, where forms of the technque were
used to resurface nasa defects n theves who were punshed for ther crmes wth
nose amputaton. Modern skn graftng methods ncude spt-thckness grafts, fu-
thckness grafts, and composte tssue grafts (Tabe 45-5). Each technque has
advantages and dsadvantages. Seecton of a partcuar technque depends on the
requrements of the defect to be reconstructed, the quaty of the recpent bed,
and the avaabty of donor ste tssue.

Table 45-5 $lassi.cation o# Skin Gra#ts

Type /escription Tickness
&in(
Spt
thckness
Thn (Thersch-Oer) 0.006-0.012
Intermedate (Bar-Brown) 0.012-0.018
Thck (Padgett) 0.018-0.024
Fu thckness Entre derms (Wofe-Krause) Varabe
Composte
tssue
Fu-thckness skn wth addtona tssue (subcutaneous
fat, cartage, musce)
Varabe
Source: Moded wth permsson from Andreass A, Bench R, Bago M, et a:
Casscaton and pathophysoogy of skn grafts. Clin Dermatol 23:332, 2005.
Copyrght Esever.

Split-Tickness Gra#ts
Spt-thckness skn graftng represents the smpest method of superca
reconstructon n pastc surgery. Many of the characterstcs of a spt-thckness
graft are determned by the amount of derms present. Less derms transates nto
ess prmary contracton (the degree to whch a graft shrnks n dmensons after
harvestng and before graftng), more secondary contracton (the degree to whch
a graft contracts durng heang), and better chance of graft survva. Thn-spt
grafts have ow prmary contracton, hgh secondary contracton, and hgh
reabty of graft take, often even n mperfect recpent beds. Thn grafts,
however, tend to hea wth abnorma pgmentaton and poor durabty compared
wth thck-spt grafts and fu-thckness grafts. Thck-spt grafts have more prmary
contracton, show ess secondary contracton, and may take ess hardy. Spt
grafts may be meshed to expand the surface area that can be covered. Ths
technque s partcuary usefu when a arge area must be resurfaced, as n ma|or
burns. Meshed grafts usuay aso have enhanced reabty of engraftment,
because the fenestratons aow for egress of wound ud and exceent contour
matchng of the wound bed by the graft. The fenestratons n meshed grafts re-
eptheaze by secondary ntenton from the surroundng graft skn. The ma|or
drawbacks of meshed grafts are poor cosmetc appearance and hgh secondary
contracton. Meshng ratos used usuay range from 1:1.5 to 1:6, wth hgher ratos
assocated wth magned drawbacks.

0ull-Tickness Gra#ts
By denton fu-thckness skn grafts ncude the epderms and the compete ayer
of derms from the donor skn. The subcutaneous tssue s carefuy removed from
the deep surface of the derms to maxmze the potenta for engraftment. Fu-
thckness grafts are assocated wth the east secondary contracton upon heang,
the best cosmetc appearance, and the hghest durabty. Because of ths, they are
frequenty used n reconstructng superca wounds of the face and the hands.
These grafts requre prstne, we-vascuarzed recpent beds wthout bactera
coonzaton, prevous rradaton, or atrophc wound tssue.

Gra#t Take
Skn graft take occurs n three phases, mbbton, noscuaton, and
revascuarzaton. Pasmatc mbbton refers to the rst 24 to 48 hours after skn
graftng, durng whch tme a thn m of brn and pasma separates the graft from
the underyng wound bed. It remans controversa whether ths m provdes
nutrents and oxygen to the graft or merey a most envronment to mantan the
schemc ces temporary unt a vascuar suppy s re-estabshed. After 48 hours a
ne vascuar network begns to form wthn the brn ayer. These new capary
buds nterface wth the deep surface of the derms and aow for transfer of some
nutrents and oxygen. Ths phase, caed inosculation, transtons nto
revascuarzaton, the process by whch new bood vesses ether drecty nvade
the graft or anastomose to open derma vascuar channes and restore the pnk
hue of skn. These phases are generay compete by 4 to 5 days after graft
pacement. Durng these nta few days the graft s most susceptbe to
deeterous factors such as nfecton, mechanca shear forces, and hematoma or
seroma.4

$o%posite Gra#ts
Composte tssue grafts are donor tssue contanng more than |ust epderms and
derms. They commony ncude subcutaneous fat, cartage and perchondrum,
and musce. Athough ess common than skn grafts, grafts of ths type are
partcuary usefu n seect cases of nasa reconstructon. Excson of the thck skn
of the nasa obue may create too deep a defect to reconstruct wth a fu-
thckness skn graft. The ear obe composte graft provdes thcker coverage wth
good coor match and a fary nconspcuous donor ste (Fg. 45-3). Smary, the
root of the hex of the ear may be used to reconstruct the aar rm, provdng skn
coverage, cartagnous support, and nterna nng n a snge technque.
Fg. 45-3.

Composte graft reconstructon of nasa obue. 12 Scarred obue from prevous
eson excson. B2 Scar excson markngs. $2 Insettng of composte ear obe skn
and subcutaneous fat graft. /2 Postoperatve day 3; note the pnk hue of
revascuarzaton. 32 Appearance at 5 weeks postoperatvey. 02 Donor ste at 5
weeks postoperatvey.

0laps
A ap s a vascuarzed bock of tssue that s mobzed from ts donor ste and
transferred to another ocaton, ad|acent or remote, for reconstructve purposes.
The dherence between a graft and a ap s that a graft brngs no vascuar pedce
and derves ts bood ow from recpent ste revascuarzaton, whereas a ap
arrves wth ts bood suppy ntact.

4ando% Pattern 0laps
Random pattern aps have a bood suppy based on sma, unnamed bood vesses
n the derma-subderma pexus, as opposed to the dscrete, we-descrbed,
drectona vesses of axa pattern aps (Fg. 45-4). Random aps are typcay used
to reconstruct reatvey sma, fu-thckness defects that are not amenabe to skn
graftng. Unke axa pattern aps, random aps are mted by ther geometry. The
generay accepted reabe ength:wdth rato for a random ap s 3:1. Exceptons
to ths rue abound, however. There are many dherent types of random cutaneous
aps that dher n geometry and mobty. A transposition %ap s rotated about a
pvot pont nto an ad|acent defect (Fg. 45-5). A &'plasty s a type of transposton
ap n whch two aps are rotated, each nto the donor ste of the other, to acheve
centra mb engthenng (see Fg. 45-2). Another common transposton ap s the
rhom(oid )Lim(erg* %ap (Fg. 45-6). The (ipedicle %ap s comprsed of two mrror-
mage transposton aps that share ther dsta, undvded margn. "otational %aps
are smar to transpostona aps but dher n that they are semcrcuar (Fg. 45-
7). $d+ancement %aps sde forward or backward aong the ap's ong axs. Two
common varants ncude the rectanguar advancement ap and the V-Y
advancement ap (Fg. 45-8). Lke transposton aps, interpolation %aps rotate
about a pvot pont. Unke transposton aps, they are nset nto defects near, but
not ad|acent, to the donor ste. An exampe of an nterpoaton ap s the thenar
ap for ngertp reconstructon (Fg. 45-9).
Fg. 45-4.

Random pattern ap archtecture. a. =
artery.
(Reproduced wth permsson from Aston
et a.5)

Fg. 45-5.

Random pattern transposton
ap.

Fg. 45-6.

1 and B2 Random pattern transposton ap, the
rhombod ap.
(Photographs reproduced wth permsson from M.
Gmbe.)

Fg. 45-7.

Random pattern rotatona ap.
(Reproduced wth permsson from Aston
et a.5)

Fg. 45-8.

Random pattern advancement ap. 12 Rectanguar advancement ap wth Burow's
trange excson. B2 V-Y advancement ap.
(Reproduced wth permsson from Aston et a.5)

Fg. 45-9.

Random pattern nterpoaton ap-the thenar ap. 12 Mdde ngertp n|ury wth
exposed bone and tendon. B2 Eevaton of dstay based random pattern thenar ap.
$2 Insettng. / and 32 Functon and form at 3 months, after skn graftng of donor
ste.
(Photographs reproduced wth permsson from M. Gmbe.)

0asciocutaneous and ,yocutaneous 0laps
The composition of a ap s ts tssue components. For exampe, a cutaneous ap
contans skn and a varabe amount of subcutaneous tssues. A fascocutaneous
ap contans skn, fasca, and ntervenng subcutaneous tssues. A musce ap
contans musce ony, whereas a myocutaneous ap contans musce wth ts
overyng skn and ntervenng tssues. An osseous ap contans vascuarzed bone
ony, whereas an osteomyocutaneous ap contans n addton musce, skn, and
subcutaneous tssues.

The contiguity of a ap descrbes ts source. Loca aps are transferred from a
poston ad|acent to the defect. Regona aps are from the same anatomc regon
of the body as the defect (e.g., the ower extremty regon or the head and neck
regon). Dstant aps are transferred from a dherent anatomc regon to the defect.
Loca, regona, and dstant aps may be pedced, n that they reman attached to
the bood suppy at ther source. Dstant aps may aso be transferred as ,ree %aps
by mcrosurgca technques; these are competey detached from the body, and
ther bood suppy s renstated by anastomoses to recpent vesses cose to the
defect.

Axa pattern aps are based on an anatomcay dened conguraton of vesses.6
Arsng from the aorta are arteres that suppy the nterna vscera and other deep
vesses that dvde to form the man artera suppes to the trunk, head, and
extremtes. They utmatey feed nterconnectng vesses that suppy the vascuar
pexuses of the fasca, subcutaneous tssue, and skn. These nterconnectng
vesses reach the skn va ether fascocutaneous (aso caed septocutaneous)
vesses that traverse fasca septae, muscuocutaneous perforators that penetrate
musce bees, or drect cutaneous vesses that traverse nether musce bees nor
fasca septae.7 Axa pattern aps, ncorporatng suprafasca tssues, are supped
by these fascocutaneous (septocutaneous), muscuocutaneous, or drect
cutaneous arteres. The nterna vscera are aso a source of axa pattern aps,
such as the |e|unum ap and omentum ap. The crcuaton of bone- and musce-
contanng aps aso s many axa n pattern. It aso s possbe to desgn oca
aps, such as V-Y advancements and rhombod aps, as axa pattern aps. The
voume of tssue reaby supped by the artera nput (and venous dranage) of an
axa pattern ap denes ts mts, not ength:breadth ratos. Ths can be cared
conceptuay. The artera tree can be descrbed n terms of angosomes, terrtores
(anatomc, dynamc, and potenta), and choke vesses.8 Each artery suppes a
bock of tssue caed an angiosome- neghborng angosomes overap. The
anatomc terrtory of an artery s dened by the mts of ts ramcatons, where t
forms anastomoses wth neghborng anatomc terrtores. The vesses that pass
between anatomc terrtores are caed choke +essels. The dynamc terrtory of an
artery s the voume of tssue staned by an ntravascuar admnstraton of
uorescen nto that artery. The potential territory of an artery s the voume of
tssue that can be ncuded n a ap that has undergone condtonng. Both the
dynamc and potenta terrtores extend beyond the anatomc terrtory of an artery.
Athough these terrtores of the artery suppyng an axa pattern ap provde
some gudance to the mts of such a ap harvest, there remans no quantabe
method to predct these safe mts exacty. By vrtue of ther dened bood suppy,
the contguty of axa pattern aps, unke that of random pattern aps, may be
oca, regona, or dstant, and pedced or free. Axa pattern aps may aso
possess some areas wth random pattern crcuaton, usuay ocated at the ap
perphery.

Conditioning refers to any procedure that ncreases the reabty of a ap. Invokng
the deay phenomenon, for exampe, has mproved the survva of aps whose use
s frequenty compcated by unpredctabe parta necross, such as the pedced
transverse rectus abdomns myocutaneous (TRAM) ap. The procedure can be
partcuary usefu n patents at hgher rsk, such as those who are obese, smoke,
or have receved radotherapy. One method of deay for the pedced TRAM ap s
to dvde a ma|or porton of ts bood suppy, the deep nferor epgastrc artery on
both sdes, approxmatey 2 weeks before transfer. In response, bood from the
anatomc angosome of the superor epgastrc artery appears to ow nto that of
the nterrupted deep nferor epgastrc artery va ntervenng choke vesses. As a
resut, the ap becomes condtoned to rey on the superor epgastrc artery. The
TRAM ap can then be transferred based on the superor epgastrc artery wth ess
rsk of ts dsta portons' becomng schemc and possby necrotc. Severa theores
have been proposed to expan the deay phenomenon, ncudng metaboc
compensatory responses to reatve schema and dataton of choke vesses;
however, ts mechansms reman ncompetey understood.9

Further subcasscatons of ap crcuaton have been ntroduced for muscuar and
fascocutaneous aps.10 Indvdua musces have been cassed by Mathes and
Naha nto ve types (I to V) accordng to ther bood suppy (Tabe 45-6). Ths
casscaton s aso apped to the respectve myocutaneous aps.
Fascocutaneous aps aso have been cassed by Naha and Mathes nto types A,
B, and C (Tabe 45-7). The ncuson of musce n a ap may serve to ncrease ap
buk (so as to obterate dead space) or to provde a functonng component wth
the harvest of ts motor nerve for coaptaton to a recpent motor nerve. The
purported advantages of musce-contanng aps over fascocutaneous aps for
use n prevousy nfected tssue beds or for fracture heang have been debated.

Table 45-5 ,ates-6aai $lassi.cation o# ,uscular 0laps

$lassi.c
ation
7ascular Supply 38a%ple
Type I One vascuar pedce Gastrocnemu
s
Type II Domnant and mnor pedces (the ap cannot survve based
ony on the mnor pedces)
Gracs
Type III Two domnant pedces Rectus
abdomns
Type IV Segmenta pedces Sartorus
Type V One domnant pedce wth secondary segmenta pedces
(the ap can survve based ony on the secondary pedces)
Pectoras
ma|or

Table 45-9 6aai-,ates $lassi.cation o# 0asciocutaneous 0laps

$lassi.ca
tion
7ascular Supply 38a%ple
Type A Drect cutaneous vesse that
penetrates the fasca
Temporopareta fasca ap
Type B Septocutaneous vesse that
penetrates the fasca
Rada artery forearm ap
Type C Muscuocutaneous vesse that
penetrates the fasca
Transverse rectus abdomns
myocutaneous ap

Wth progressve advancements n ap transfer technques and an understandng
of mcrovascuar ap anatomy, pastc surgeons have steady ncreased the
number and varety of avaabe aps, thereby mprovng the resuts of ap
reconstructons. In addton, ths knowedge has reduced the morbdty assocated
wth ap harvest. Perhaps the most mportant advancement n ap surgery wthn
the ast two decades has been the ntroducton of the perforator ap.11 Perforator
aps evoved from the observaton that the musce component of myocutaneous
aps served ony as a passve carrer of bood suppy to the overyng
fascocutaneous tssues (fasca, skn, and ntervenng subcutaneous tssues).
Prevous to ths, t had been deemed necessary to ncude the musce for reabe
harvest of fascocutaneous tssues supped by ts muscuocutaneous perforators,
even f t was not necessary to ncude that musce for the reconstructon. Ths
unfortunatey caused an unnecessary muscuar dect at the donor ste, and for
ths reason these aps were sometmes abandoned. The ntroducton of
ntramuscuar retrograde dssecton technques, however, aowed the
skeetonzaton of a muscuocutaneous perforator from ts encasement wthn a
musce bey, whch spared that musce from ap harvest and preserved ts donor
ste functon.7,11 Further renement of ths concept gave rse to the harvest of
cutaneous aps based on any vesse that penetrated the fasca, whch preserved
the musce (when the vesse was a muscuocutaneous perforator) as we as the
fasca (by suprafasca dssecton). Wthn the ast decade, free-stye ap harvest
has aso been ntroduced.12 Wth a handhed Dopper utrasound probe, the
surgeon s abe to dentfy an artera suppy to amost any area of skn wth the
desred reconstructve characterstcs and trace that pedce n retrograde fashon
aong whatever drecton t takes, preservng donor ste fasca and musce as
necessary. Athough the exact denton of what a perforator ap s remans
contentous, ts advantages reman cear: reduced donor ste morbdty, reduced
ap buk, and ncreased exbty n choosng desred ap components for
reconstructon. The crcuaton of perforator aps s axa n pattern; consequenty,
they can be transferred as pedced sand aps or by mcrovascuar free tssue
transfer.

0ree Tissue Trans#er
A free tssue transfer (or transpantaton), often referred to as a ,ree %ap
procedure, s an autogenous transpantaton of vascuarzed tssues. Any axa
pattern ap wth pedce vesses of a sutabe dameter can be transferred as a free
ap. Ths nvoves three man steps: (a) compete detachment of the ap, wth
devascuarzaton, from the donor ste; (b) revascuarzaton of the ap wth
anastomoses to bood vesses n the recpent ste; and (c) an ntervenng perod of
ap schema. Fap crcuaton must be restored wthn a toerabe schema tme.

Gven the sma dameter of most ap pedce vesses (usuay between 0.8 and 4.0
mm), these anastomoses are usuay performed usng an operatve mcroscope
that provdes dedcated umnaton and between 6x and 40 magncaton. Any
surgery performed wth the ad of an operatve mcroscope s termed microsurgery-
such anastomoses are therefore termed micro+ascular anastomoses. Hgh-
magncaton surgca oupes are usuay used for ap harvest, especay for
dssectng the ap pedce, because they aow greater operator freedom. Asde
from mcrovascuar anastomoss, mcrosurgca technques ncude mcroneura
coaptaton, mcroymphatc anastomoss, and mcrotubuar anastomoss.

The rst successfu free tssue transfer n humans was transfer of a |e|una free ap
for cervca esophagus reconstructon performed n 1957; however, the surgeons
dd not use mcrovascuar surgery for the anastomoses. The rst micro+ascular
free tssue transfers n humans were carred out durng the ate 1960s and eary
1970s. Free aps were ntay consdered to be a ast-resort opton to reconstruct
the most compex defects. However, as a resut of mproved mcrosurgca
technques and mcronstrumentaton, as we as proper patent and free ap
seecton and ehectve postoperatve montorng methods, the success rates have
ncreased to exceed 95%.13 Today, free tssue transfer s often the rst-choce
treatment for many defects and s no onger consdered the ast-dtch ehort. It s
now ubqutousy used n approprate patents by reconstructve pastc surgeons
wordwde.

The predetermnng factor n free ap faure s occuson of ts anastomotc fene
bood suppy due to thromboss. As enumerated by Vrchow's trad, any factors that
ater norma amnar bood ow, cause endothea damage, or change the
consttuton of bood (producng hypercoaguabty) ncrease the rsk of thromboss
(Tabe 45-8).14 Avodance of ths compcaton therefore begns wth a thorough
patent evauaton for the presence of acqured or nherted thrombophc
tendences. The patent's hemodynamc status nuences that of the free ap and
shoud be optmzed. The ehect of tobacco smokng on free ap success has been
debated, wth some arger retrospectve studes reportng no dherence n
thromboemboc compcatons; however, smokng s we known to ahect wound
heang.13,15 Smokng, and the use of potentay vasoconstrctve agents, such as
cahene, shoud be avoded for severa weeks before a free ap procedure. The
restoraton of norma amnar bood ow and avodance of endothea damage are
addressed prncpay by carefu ap nsettng and metcuous mcrovascuar
surgca technque.

Table 45-: Tro%bogenic 0actors Tat $an 1;ect 0ree 0lap Pedicles and
1nasto%oses

1ltered La%inar Blood
0lo!
3ndotelial /a%age Hypercoagulability
Tenson or ntma
maagnment at the
anastomoss ste; twstng,
knkng, compresson, or
vasospasm of pedce
vesses
Iatrogenc damage (e.g.,
back-waed anastomotc
suture, poor vesse
handng, too many
sutures)
Acqured thrombophc
tendency (e.g., pregnancy,
paraneopastc Trousseau's
syndrome, antphosphopd
antbody syndromes)
Nearby ntraumna
structures (e.g.,
atheroscerotc paque,
venous vaves, back-waed
anastomotc suture)
Prevous vesse damage
(e.g., atherosceross,
trauma)
Heredtary thrombophas (e.g.,
actvated proten C resstance,
proten C/proten S decency,
hyperhomocystenema)

Pannng a free ap goes beyond a smpe cacuaton of matchng ap and defect
dmensons and tssue characterstcs. The surgeon must, n addton, consder
severa mportant techncates: what ap pedce ength and sze are requred
(ahected by ap choce), whch recpent vesses to use, how to orent
anastomoses (end to end or end to sde), how to dea wth msmatched donor and
recpent vesse dmensons, how to overcome unheathy donor and/or recpent
vesses (e.g., traumatc dssecton, scarred surgca ed due to prevous operaton
or radotherapy), how to nset ap tssues (to maxmze functona and cosmetc
resuts wthout detrment to ap crcuaton), how to route the pedce (to restore
norma bood ow wthout pedce knkng, twstng, or compresson), how to
poston the patent (especay f the ap s to be nset over mobe soft tssue or
|onts), how to pace postoperatve dressngs (so as to produce no compresson of
the ap or pedce), and what donor ste morbdty w key resut (there s a rsk-
benet decson between defect severty and ap choce).16 In addton, the
surgeon must have a sutabe backup pan to overcome ntraoperatve troubes; for
exampe, nsumcent pedce ength can be addressed wth an nterpostona ven
graft ad|onng the donor and recpent vesses, and atrogenc vesse n|ury or
severey aberrant anatomy may necesstate use of a backup ap or backup
recpent vesses.13

A cear understandng of the bood suppy to the free ap and ts tssue
components s a prerequste to harvestng a vabe free ap. Pedce vesses must
be dented and protected, and handed mnmay and atraumatcay to avod
thrombogenc factors (see Tabe 45-8). Metcuous technque aso reduces the rsk
of vasospasm, but the atter can be ameorated by topca docane or papaverne
shoud t occur. Crtca vesses connectng ap components must aso be
recognzed and preserved. Under mcroscope magncaton, the donor and
recpent vesses shoud be dssected back to heath. The presence of, for exampe,
venous vaves, atheroscerotc paques, ntma trauma, and ntraumna proapse
of adventta tssue at or ad|acent to the anastomoss ste ncreases the rsk of
thromboss. The vesse ends shoud be ceared of peradventta tssues for 3 to 5
mm wth sharp dssecton under the mcroscope. Peradventta dssecton shoud
be mted to ths extent, so as to avod potenta devascuarzaton of the vesse
wa by remova of the vasa vasorum and prevent the subsequent deayed
deveopment of a peranastomotc pseudoaneurysm. Adventtectomy aso heps
reeve vasospasm by ncreasng compance of the vesse wa and by nducng a
oca sympathectomy ehect. The vesse ends usuay are stabzed wth a doube
approxmatng mcrovascuar camp for anastomoss. Interrupted sutures or, ess
commony, contnuous sutures can accompsh the anastomoss. The mcroneede
typcay has a three eghths crce curvature and s between 30 and 150 m n sze.
Its monoament mcrosuture s usuay between 9-0 and 11-0 caber. The
dmensons of the vesses to be anastomosed dene the choce of mcroneede and
mcrosuture. Less commony, suture aternatves such as brn adhesves or aser
wedng (these reman argey expermenta) and mechanca anastomotc devces
(e.g., venous coupers) may be used. Tranguatng or bsectng suturng technques
can hep to acheve an even pacement of sutures. Normay, each suture shoud
ncude the fu thckness of both vesse was, none shoud catch the opposte
vesse wa (whch causes dsastrous umna occuson and ntma trauma), and
the sze of each bte shoud approxmate the vesse wa thckness. The
conguraton of the anastomoss can be ether end to end (Fg. 45-10), f the dsta
crcuaton can be adequatey preserved, or end to sde (Fg. 45-11) f the dsta
crcuaton must be preserved, as n the case of an arteray compromsed
extremty supped by one domnant vesse. An end-to-sde orentaton may aso be
usefu to overcome dramatcay msmatched donor-recpent vesse dmensons.
Whatever the method chosen, mcroanatomc dherences between the vesses
shoud be respected so as to acheve accuratey approxmated ntma surfaces n a
tenson-free anastomoss, devod of redundancy that mght promote knkng.13
Fg. 45-10.

1 through /2 End-to-end
anastomoss.

Fg. 45-11.

1 through 32 End-to-sde
anastomoss.
The cnca montorng of a free ap shoud start durng ap harvest, especay
before ts pedce s dvded. A free ap that s struggng to mantan norma
perfuson characterstcs durng harvest most key has nsumcent crcuaton,
whch may be due to artera or venous compromse, or a combnaton of both
(Tabe 45-9). Fap compromse may be due to reversbe factors such as pedce
knkng, tensonng, or twstng; patent hemodynamc compromse; or an overy
arge ap harvest for the chosen pedce vesses. If poor ap perfuson contnues
despte the absence or correcton of a these factors, an nherent ap probem or a
crtca vascuar n|ury to the ap or ts pedce must be consdered, and t may not
be safe to contnue ts harvest. Ths s one cear exampe of a stuaton n whch a
backup pan may requre executon.

Table 45-< $linical Signs o# 1rterial and 7enous $o%pro%ise in a
0ree 0lapa

$linical Sign 1rterial
$o%pro%ise
7enous $o%pro%ise
Coor Becomng paer Increasngy reddsh or
purpsh
Temperature Becomng cooer Becomng warmer
Tssue turgor Reducng Increasng
Capary re
tme
Becomng sower Becomng faster
Pnprck
beedng
Increasngy
suggsh
Ouckenng (and darkenng)
aNote that venous and artera compromse may coexst, and one may ead to the other.

Cnca ap montorng contnues after successfu restoraton of artera now and
venous outow. The manstay of postoperatve free ap montorng s cnca
assessment (see Tabe 45-9), athough suppementary nstrument montorng aso
can be hepfu. Dopper utrasound assessment of artera and venous sgnas s
usefu for montorng bured or conceaed aps. If ap perfuson was heathy before
dvson of ts donor ste pedce, then poor perfuson after anastomoses s key
due to ether a technca error or nsumcent systemc hemodynamcs. The atter
usuay s correctabe by ensurng that the patent and the patent's envronment
are sutaby warm and by ntatng IV cood chaenge or, f ndcated, bood
transfuson. Numerous potenta technca errors, whch have been descrbed n the
earer paragraphs on pannng and anastomoss technque, may occur. Routne
postoperatve patent montorng ncudes measurement of tota ud nputs,
urnary catheter output (whch shoud be >1 mL/kg per hour), core temperature,
and artera bood pressure (systoc pressure shoud be >100 mmHg), as we as
puse oxmetry. The patent and free ap are best montored n an ntensve care
settng by experenced stah unt both are stabe enough for routne ward
assessments.13

Occuson of the anastomoss most commony arses from nterna thromboss or
from externa compresson of the pedce, such as from surroundng tssues, ud
accumuaton (e.g., hematoma and tssue edema), or overy tght dressngs or skn
sutures. Because there s a threshod of schema beyond whch a ap w sustan
rreversbe tssue and/or mcrocrcuatory damage, t s mportant that the eary
sgns of ap crcuatory compromse be recognzed as qucky as possbe and the
underyng probem dagnosed and corrected prompty f ap heath s to be
restored successfuy. Dherent tssues toerate dherng duratons of schema n
correaton wth ther tssue-specc basa metaboc rate. Athough coong free
aps (to reduce basa metaboc rate) has a varaby protectve ehect n
expermenta settngs, t appears that ths practce contrbutes tte to mprovng
free ap success n the cnca settng as ong as warm schema tmes are kept to
<4 hours for most tssues; exceptons ncude bowe aps, whch are more
susceptbe to schema.13

Gven that the predsposng factor for free ap faure s thromboss formaton, t s
understandabe that pastc surgeons have ooked to antcoaguant therapes n an
ehort to mprove success rates. The routne use of antcoaguants remans
controversa. Athough such drugs, ncudng the dextrans, asprn, heparn, and
aso some brnoytcs, appear beneca n expermenta settngs, arge cnca
tras have faed to show any concusve assocatons between ther use and ether
free ap success or faure rates.17 It seems ntutve to use these drugs for fang
free aps as an ad|unctve measure aongsde operatve re-exporaton and surgca
nterventon. The surgeon must be aware of ther contrandcatons and recognze
that ther sde ehects, apart from beedng, are occasonay serous. Venous
congeston may be addressed by surgca measures as we as by appcaton of
medcna .irudo medicinalis eeches (wth concomtant $eromonas hydrophilia
prophyaxs) or by chemca "eechng" (topca heparn combned wth derma
punctures).

Unfortunatey, the "no-reow" phenomenon s occasonay wtnessed and eads to
rreversbe ap faure. Ths descrbes a stuaton n whch no venous return drans
nto the pedce ven of the ap, even though adequate artera now passes the
artera anastomoses and s seen to enter the ap tssues. The no-reow
phenomenon sometmes foows an extended schemc nsut and appears to be a
sef-perpetuatng cyce of endothea ceuar sweng, nammatory
vasoconstrcton, mpared mcrocrcuatory ow, stass, mcrocrcuatory
thromboses, progressve schema, and ap faure.13

Despte these potenta probems, free ap success rates exceed 95% n
experenced hands.18 There s no doubt that ncreasng mcrosurgca experence s
crtca to mprovng free ap success rates. The aboratory settng s an exceent
envronment n whch to progress beyond the eary porton of one's earnng curve
through supervsed mcrosurgca tranng and executon of mcrovascuar
anastomoses and mcrovascuar free ap procedures n sma anmas.

Tissue 38pansion
Athough skn grafts and oca aps are very usefu n reconstructng many
superca defects, they are not wthout ther drawbacks. Both eave donor ste
defects wth cosmetc and/or functona sequeae. Grafts are mted n coor match
and durabty, whereas oca aps may suppy nsumcent tssue and produce
contour rreguartes. The advent of tssue expanson has created the potenta to
greaty ncrease the amount of oca, we-matched tssue that can be advanced or
transposed as a ap whe decreasng donor ste morbdty.

The most common method of skn expanson nvoves the pacement of an
natabe scon eastomer baoon wth an ntegrated or remote port beneath the
skn and subcutaneous tssue foowed by sera naton wth sane. After
competon of expanson, usuay over weeks to months, the expander s removed
and the redundant overyng skn may be advanced nto an ad|acent defect.
Expanders are now avaabe n a muttude of shapes and szes that can be taored
to the reconstructon. In breast reconstructon the tssue expander s repaced wth
a permanent mpant nstead of usng the tssue as a ap to re-create the voume
of the breast mound. Hstoogcay, expanded skn demonstrates thckened derms
wth enhanced vascuature and dmnshed subcutaneous fat. Studes have shown
that the skn expanson s due not merey to stretch or creep but aso to actua
generaton of new tssue.19

The technque of tssue expanson comes wth ts share of potenta compcatons,
ncudng nfecton, hematoma, seroma, expander extruson, mpant faure, skn
necross, pan, and neurapraxa. Furthermore, an nated expander s certany a
very vsbe, abet temporary, deformty that may cause patents much dstress.

Despte these mperfectons, tssue expanson has become a ma|or treatment
modaty n the management of gant congenta nev, secondary reconstructon of
extensve burn scars, scap reconstructon, and breast reconstructon. The
technque has permtted the pastc surgeon to perform reconstructons wth tssue
of smar coor, texture, and thckness wth mnma donor ste morbdty.

Pediatric Plastic Surgery
$le#t Lip and Palate
Orofaca ceftng s the most common congenta anomay and s known to occur n
1 n 500 ve whte brths.20 The ncdence s ower n Afrcan Amercans and hgher
n Natve Amercans and Asans. Ceftng of the p and/or paate s fet to occur
around the eghth week of embryogeness, ether by faure of fuson of the meda
nasa process and the maxary promnence or by faure of mesoderma mgraton
and penetraton between the epthea bayer of the face. The cause of orofaca
ceftng s fet to be mutfactora. Factors that key ncrease the ncdence of
ceftng ncude ncreased parenta age, drug use and nfectons durng pregnancy,
smokng durng pregnancy, and a famy hstory of orofaca ceftng. The ncreased
chance of ceftng when there s an ahected parent s approxmatey 4%.

The primary palate s dened as a tssue anteror to the ncsve foramen,
ncudng the anteror hard paate (premaxa), aveous, p, and nose. The
secondary paate ncudes everythng posteror to the ncsve foramen, ncudng
the ma|orty of the hard paate and the soft paate (veum). Ceftng can nvove the
p and nose, wth or wthout a paata ceft. Cefts of the p and/or paate are rst
cassed as unatera or batera, and then as compete or ncompete (Fg. 45-
12). Compete cefts of the p ahect the entre p and extend up nto the nose.
Incompete cefts ahect ony a porton of the p and contan a brdge of tssue
connectng the centra and atera p eements, referred to as Simonart's (and.
Fg. 45-12.

12 Unatera ceft p and paate. B2 Batera ceft p and paate. $2 Incompete
unatera ceft p.

Treat%ent Protocol
Consderabe controversy remans over the detas of the tmng, technque, and
protoco for treatng chdren wth orofaca ceftng. The treatment protoco
descrbed n ths chapter s accepted at many arge ceft centers around the Unted
States. A nfants born wth ceft-cranofaca anomaes benet from care by a
specazed team dedcated to the treatment of congenta anomaes. Today, ths s
wdey accepted as the standard of care. Often, patents are seen prenatay after a
dagnoss s made usng sophstcated antenata utrasonography. The prenata
consutaton has proven to be beneca to parents, servng to dspe fears and
uncertantes, and assurng them that treatment exsts. After the nfant's brth, a
team evauaton occurs, and nput s obtaned from the surgeon, speech and
anguage pathoogst, soca worker, cranofaca orthodontst, genetcst,
otorhnoaryngoogst, and pedatrcan. For nfants born wth orofaca ceftng,
nta concerns reate to successfu feedng and breathng. Infants wth paata
cefts cannot generate negatve pressure when suckng and therefore need mk
dspensed nto ther mouths from a specazed nurser when they make suckng
motons. Once adequate nutrton and a safe arway are ensured, attenton s
turned to the ceft anomay. Attempts to essen the deformty and set the stage for
the surgca repar of the p and nose begn wth a process known as presurgical
in,ant orthopedics )PSI/*, whch ncudes procedures such as nasoaveoar modng
(NAM) (Fg. 45-13). NAM repostons the neonata aveoar segments, brngs the p
eements nto cose approxmaton, stretches the decent nasa components, and
turns wde compete cefts nto the morphoogy of narrow "ncompete" cefts. After
PSIO wth NAM, the dentve snge-stage ceft p and nose repar s performed at
3 to 6 months of age. Wth ths nta operaton, the p deformty s repared and a
prmary nasopasty reconstructs the ceft p nasa deformty. If the famy does not
have access to PSIO or have the resources for ths tme-ntensve therapy, a ceft
p adheson can be performed as an nta stage n the repar. The premnary ceft
p adheson untes the upper p and nasa s, truy convertng compete cefts nto
ncompete cefts. A ceft p adheson s performed n the rst or second month of
fe, and the dentve ceft p and nose repar foows at 4 to 6 months. After the
dentve ceft p and nose repar, the ceft paate s repared n a snge stage at 9
to 12 months of age.
Fg. 45-13.

12 Compete eft-sded ceft p, nose, and paate. B2 Nasoaveoar modng. $2 After
nasoaveoar modng, preoperatve appearance before ceft p and nose repar. /2
Fronta vew after ceft p and nose repar. 32 Worm's-eye vew after ceft p and
nose repar.

=nilateral $le#t Lip
The unatera ceft p s casscay assocated wth a ceft p nasa deformty. The
ceft p nasa deformty ncudes atera, nferor, and posteror dspacement of the
aar cartage. Ths resuts from the decent and cefted underyng skeeton as
we as the unopposed pu of the cefted orbcuars ors musce abnormay
nserted on the aar base (Fg. 45-14A). The maxary mnor segment (the smaer
aveoar/maxary segment on the cefted sde) s coapsed meday. The process
of unatera ceft p repar can be thought of as "phtra subunt reconstructon."
The goa of the operaton s to eve Cupd's bow and reconstruct the centra
phtrum of the p, deay pacng the ncson and subsequent scar as cose to the
norma phtra coumn as possbe. The surgca repar s performed under genera
anesthesa, and oca anesthesa contanng epnephrne s used. Many dherent
technques of ceft p and nose repar have been proposed; however, most of the
commony used procedures are varatons of a "rotaton-advancement"
procedure.21 The rotaton-advancement procedure, as champoned by Mard (Fg.
45-14B), rotates the phtra subunt of the centra p downward to eve Cupd's
bow as the atera p eement s advanced nto the defect created by the downward
rotaton of the phtrum. Some surgeons choose to perform prmary cosure of the
aveoar ceft at the tme of prmary p and nose repar, caed a
gingi+operiosteoplasty. If the aveoar ceft s to be repared, the
gngvoperosteopasty s performed by rasng mucoperostea aps wthn the
aveoar ceft margn and reapproxmatng them across the aveoar ceft defect.
Ths creates a bony tunne cosed wth perostea aps and factates the
generaton of bone n the aveoar defect. It s accepted today that some form of
prmary nasopasty shoud be performed at the tme of prmary dentve p repar.
Technques to reease and reposton the nasa tp cartages, as we as the aa, are
performed wth varatons of tp rhnopastes usng suture methods. Some
surgeons choose to use postoperatve nterna and/or externa spnts to mantan
the nasa correcton acheved at surgery durng the heang process.
Fg. 45-14.

12 Unatera ceft p and nose deformty. B2 The rotaton-
advancement repar.

Bilateral $le#t Lip
In the compete batera ceft p and nose deformty, the centra p eement, caed
the prola(ium, s entrey separate from the rest of the upper p. The proabum s
dspaced on top of the centra aveoar segment, caed the premaxilla, contanng
the unerupted four centra ncsors. Often, the premaxa and proabum are
outwardy dspaced. Ths s referred to as a %ya0ay premaxilla. For the chd wth a
compete batera ceft p and nose, PSIO s a very mportant step n preparng the
chd for dentve p and nose surgery by retractng the premaxa nto the
maxary arch, repostonng the p segments, and stretchng the rudmentary
coumea. Batera ceft p and nose repars often are versons of straght-ne
repars, wth the Muken technque beng the more commony performed (Fg. 45-
15). In the batera ceft p deformty, the new phtrum s made from the
proabum and s unted to the atera p eements on top of the repared orbcuars
ors musce.22
Fg. 45-15.

Muken batera ceft p and nose repar. a = aa nas; c = hghest pont of
coumea nas; cph = crsta phtr nferor; cphs = crsta phtr superor; s = abae
superus; n = nason; prn = pronasae; sn = subnasae; sto = stomon.

$le#t Palate
Durng the eghth to twefth weeks of gestaton, the mandbe becomes more
prognathc, the tongue drops from beneath the cefted atera paatne processes,
and the paata sheves mgrate upward nto a more horzonta poston and fuson
occurs. A ceft paate resuts from the faure of fuson of the two paata processes.
As wth aba ceftng, soated cefts of the paate are mutfactora n etoogy, and
soated cefts of the paate are more key to be assocated wth other anomaes.
Between 8 to 10% of soated cefts of the paate are assocated wth the 22q
deeton of veocardofaca syndrome.23

The man goa of ceft paate surgery s to hep the patent attan norma speech,
whch resuts from veopharyngea competence. Durng speech, the soft paate, or
veum, s moved posterory and superory, prmary by the evator paatn musce
sng that suspends the veum from the sku base. Veopharyngea competence s
obtaned durng attempted speech when the veum approxmates the posteror
pharyngea wa, preventng ar and qud from regurgtatng nto the nasa cavty.
Veopharyngea competence aows ntraora pressure to be but up for speech
sounds. A ceft paate precudes ths from occurrng and resuts n veopharyngea
ncompetence, or VPI. Because t s mpossbe for the ora and nasa cavtes to be
parttoned n the patent wth a ceft paate, t s aso dmcut for the patent to
deveop negatve ntraora pressure for an ehectve suck. Therefore, specazed
nursers are used to dspense qud nto the nfant's mouth durng the suckng
motons. Chdren wth cefts of the paate have an ncreased ncdence of otts
meda; ths may be reated to the abnormaty of the vear muscuature and
nehectve functon of the eustachan tube. The ncreased ncdence of otts meda
can resut n hearng oss f not treated appropratey. In addton, VPI and nasa ar
escape durng speech resuts n hypernasa speech.

As wth the repar of ceft p and nose, the tmng, technque, and protocos for
ceft paate repar are controversa. Most agree that paate repar shoud be
performed before the deveopment of speech. The ceft paate usuay s repared
when the nfant s between 6 and 18 months of age. Ceft paate repar aso s
performed under genera anesthesa, wth the head sghty hyperextended and a
retractor, such as the Dngman mouth gag, paced ntraoray to retract the tongue
and endotrachea tube. An epnephrne souton s n|ected nto the paate.
Technques of hard paate cosure ncude the use of unpedced hard paate
mucoperostea aps as n the Ward-Veau-Kner repar or bpedced hard paate
mucoperostea aps as n the von Langenbeck repar. Both the unpedced and
bpedced hard paate paatopasty technques rey on the greater paatne
neurovascuar pedce. Soft paate or vear cosure technques are dvded nto
straght-ne and Z-pasty procedures. Wth ether a straght-ne or Z-pasty vear
repar, the evator paatn musce shoud be ndependenty repared; ths s caed
an intra+elar +eloplasty. The cefted evator s dented coursng sagttay n an
anteror-posteror drecton, abnormay nserted onto the posteror edge of the
hard paate. In ntravear veopasty, t s reeased from the posteror edge of the
hard paate n the mdne and dssected free from abnorma attachments to the
aponeuross of the tensor ve paatn musce and superor constrctor ateray.
After ts compete reease, the evator paatn musce s unted n the mdne, wth
reconstructon of the evator musce sng that suspends the veum from the sku
base and ads n veopharyngea competence.

The authors prefer the doube opposng Z-pasty technque of soft paate or vear
reconstructon known as the 1urlo0 palatoplasty.24 The procedure uses four
tranguar aps, two ora and two nasa, wth the posterory based aps contanng
the reeased evator musces. The Z-pasty engthens the soft paate, prevents
ongtudna scarrng from a straght-ne repar, and produces a secondary
pharyngopasty ehect by narrowng the veopharyngea port (Fg. 45-16).
Fg. 45-16.

12 Markngs for the Furow doube opposng Z-pasty paatopasty. B2 Rasng the ora
aps n a Furow paatopasty. $2 The compete dssecton of a Furow paatopasty.

Compcatons of paatopasty ncude wound-heang probems resutng n a
breakdown of the suture ne and the deveopment of a stua. The terature
reports stua rates rangng from approxmatey 1 to 20%. Treatment of paata
stuae s partcuary chaengng, because the recurrence rates have been noted
to approach 96%. The second most common compcaton of paatopasty s the
ncompete correcton of speech and the deveopment of postoperatve VPI. The
terature reports postoperatve VPI rates rangng from 10 to 40%. Some of the best
rates of veopharyngea competence have been reported wth the Furow doube
opposng Z-pasty paatopasty. Postoperatve VPI s treated wth pharyngopasty:
ether a posteror pharyngea ap pharyngopasty or a sphncter pharyngopasty. A
posteror pharyngea ap s a statc ap formed from the posteror pharyngea wa
ncudng mucosa and a porton of the superor constrctor musce. The mdne
superory based pharyngea ap s nset nto the posteror free edge of the soft
paate, permanenty attachng t to the posteror pharyngea wa. The sphncter
pharyngopasty has been reported to nvove creaton of a dynamc sphncter made
wth the batera posteror tonsar pars contanng the paatopharyngeus
musce. The superory based tonsar pars are eevated from the atera pharynx
and nset nto a horzonta ncson on the posteror pharyngea wa at the eve of
the adenod pad.

$ranio#acial 1no%alies
History> ?+er+ie!> and $lassi.cation Syste%
Cranofaca surgery s the subspecaty of pastc surgery deang wth hard and
soft tssue deformtes of the cranofaca skeeton, treatng the congenta,
deveopmenta, and acqured defects of the crana and/or faca skeeton.
Cranofaca surgery addresses the functona and equay mportant appearance-
reated ssues surroundng these deformtes. Attemptng to separate the functona
mparment from the appearance-reated ssues s arbtrary, because t can be
argued that the most mportant functon of a face s to ook ke a face.25
Numerous studes have estabshed the mportance of faca form and the
sgncant emotona mpact that faca deformtes have on a person's fe and
sense of sef.

The ed of cranofaca surgery nds ts orgns n the aftermath of the word wars
and the need to treat massve faca n|ures. In 1967, Dr. Pau Tesser, now
recognzed as the father of cranofaca surgery, rst pubcy presented hs
concepts of usng wde exposure and a transcrana route to treatng cranofaca
deformtes wth arge segmenta movements of bone. An Amercan dscpe of Dr.
Tesser, Dr. Lnton Whtaker of the Chdren's Hospta of Phadepha, workng wth
the Commttee on Nomencature and Casscaton of Cranofaca Anomaes of the
Amercan Ceft Paate-Cranofaca Assocaton, presented a smpe and practca
casscaton system for cranofaca anomaes (Tabe 45-10).

Table 45-1@ $lassi.cation o#
$ranio#acial 1no%alies

I. Cefts
a. Centrc
b. Acentrc
II. Synostoses
a. Symmetrc
b. Asymmetrc
III. Atrophy, hypopasa
IV. Neopasa, hypertrophy,
hyperpasa
V. Uncassed

It s the standard of care today that an nterdscpnary team of experts wth
specazed knowedge and tranng n treatng chdren wth cranofaca anomaes
care for chdren who have such anomaes. The preoperatve work-up and
evauaton must be thorough and shoud ncude magng (computed tomography,
or CT; magnetc resonance magng, or MRI; cephaography), photography, bood
work, anesthesa consutaton, and other components as the condton dctates.
Cranofaca procedures are often ong, compcated surgeres of sgncant
magntude, wth an attendant rsk of bood oss, serous morbdty, and even
mortaty. Sgncant bood oss s a reastc possbty, and preparaton for bood
conservaton and transfuson must be made. The routne surgca approach to the
cranofaca skeeton can be va a corona ncson, and after a bfronta cranotomy,
the orbta and faca skeeton can be addressed. Bone grafts for reconstructon can
be spt cavara grafts or, aternatvey, grafts from the rbs or ac crest. Rgd
xaton s obtaned wth boresorbabe pates, screws, and sutures. Despte the
magntude of the procedures, sgncant morbdty (bndness, bran n|ury,
sgncant nfecton, cerebrospna ud eak, ntracrana hematoma) or mortaty s
rare.

$ranio#acial $le#ts
The rare cranofaca cefts have been subcassed by Tesser (Fg. 45-17). The
Tesser casscaton of cranofaca cefts consders the orbt as the center around
whch the cefts radate as the spokes of a whee, numbered from 0 to 14. The
faca cefts (0 to 7) and ther crana extensons (8 to 14) are often assocated and
tota 14 (Fg. 45-18). Treacher Cons syndrome (Fg. 45-19), aso known as
mandi(ulo,acial dysostosis, s a type of cranofaca ceftng dsorder representng
batera 6-7-8 cefts. Ths autosoma domnant dsorder wth varabe penetrance
has the foowng manfestatons: hypopasa of the zygomas, asymmetry and
hypopasa of the mandbe, ear anomaes, and coobomas of the ower eyeds.
Cranofaca mcrosoma, aso known as hemi,acial microsomia, can be cassed as
a form of ceftng as we (Fg. 45-20). Manfestatons of ths anomay usuay
nvove the hard and soft tssue of one haf of the cranofaca skeeton. Deformtes
range n severty from compete absence of an ahected faca component (gobe,
mandbe, ear) to md asymmetres. Ear deformtes range from compete absence
of the ear to ony preaurcuar skn tags. Smary, the eye deformtes range from
compete absence of the gobe to varous anomaes ncudng epbubar dermods.
Hypopasa of the tempora sku, maxa and zygoma, and orbt are seen n varyng
degree and ahect the underyng skeeton as we as the overyng soft tssues. The
cassca deformty of hemfaca mcrosoma ahects the mandbe. Hypopasa of
the hemmandbe, as we as the maxa, resuts n denta maoccusons (Fg. 45-
20C). Mandbuar hypopasa may range from mnor underdeveopment of
otherwse norma components to compete absence of the condye, ramus, and
proxma body. Treatment of hemfaca mcrosoma ncudes management of the
arway and attenton to other functona condtons. Treatment of the mandbuar
deformty ncudes dstracton osteogeness durng growth and orthognathc
procedures at skeeta maturty. Ear deformtes are reconstructed wth technques
usng costa cartage and oca soft tssue. Soft tssue decences of the hemface
can be treated wth fat n|ectons, derma-fat grafts, or free tssue transfer. Orbta
hyperteorsm s yet another type of mdne cranofaca (0-14) ceftng. /r(ital
hypertelorism s dened as a aterazaton of the entre orbt, ncreasng the
ntraorbta dstance and resutng from mdne condtons such as encephaocees,
frontonasa dyspasa, and syndromc cranosynostoss. The treatment of severe
orbta hyperteorsm ncudes a transcrana approach to four-wa orbta box
osteotomes, resecton or treatment of the abnorma mdne process, mobzaton,
medazaton of the orbta compexes, and nasa reconstructon wth a cantever
nasa bone graft.
Fg. 45-17.

Tesser's casscaton of cranofaca
cefts.

Fg. 45-18.

Cranofaca ceft.
|Reproduced wth permsson from Losee |, Krschner R (eds): Comprehensi+e Cle,t
Care, 1st ed. New York: McGraw-H Professona, 2008, Chap. 27, Fg. 3.|

Fg. 45-19.

Chd wth Treacher Cons syndrome. 12 Fronta vew. B2 Latera vew. $2 Three-
dmensona computed tomographc scan of the cranofaca skeeton.

Fg. 45-20.

Chd wth eft-sded cranofaca/hemfaca mcrosoma. 12 Fronta vew. B2 Latera
vew. $2 Bte pane.

$raniosynostosis
The cranosynostoses are a group of dsorders that resut from the abnorma
obteraton or premature fuson of the crana sutures. The cranosynostoses can
be subdvded nto smpe or snge-suture cranosynostoses, and compex,
syndromc, or mutpe-suture cranosynostoses. The crana sutures aow for the
norma growth of the sku, and therefore the cassc presentaton of
cranosynostoss s an abnorma head shape. The resutant abnorma head shapes
are secondary to an nhbton of sku growth at rght anges to the fused suture
and a compensatory overexpanson of the sku perpendcuar to the fused suture
nto areas wth open sutures. These abnorma head shapes provde a bass for the
casscaton of cranosynostoses. In addton to appearance-reated deformtes
resutng from cranosynostoss, mportant functona aspects ncude the potenta
for ntracrana hypertenson, whch may resut from bran growth restrcted by an
unyedng sku. The chances of ntracrana hypertenson ncrease wth the
number of sutures ahected. Bndness and menta decences secondary to an
ncrease n ntracrana pressure can key be prevented by the surgca expanson
of the cranum to reease the fused suture, correct the abnorma head shape, and
remode the sku. The standard procedure used today n the correcton of these
synostotc deformtes s fronto-orbta advancement. Fronto-orbta advancement,
performed usng a transcrana approach, ncudes a fronta cranotomy and orbta
repostonng. The compex or mutsutura synostoses are often syndromc,
resutng from gan-n-functon mutatons of the brobast growth factor receptors
(FGFR1, FGFR2, FGFR3). These syndromes of cranosynostoss ncude the Apert,
Crouzon, Pfeher, and Saethre-Chotzen syndromes. The syndromc
cranosynostoses not ony ncude bcorona synostoss but aso nvove the mdface
wth resutng exorbtsm and mdface hypopasa. Muteve arway anomaes,
obstructve seep apnea, cornea exposure, ntracrana hypertenson, feedng
dmcutes, and severe maoccuson are some of the assocated anomaes found n
chdren wth syndromc cranosynostoses. In addton to fronto-orbta
advancement, faca osteotomes (.e., Le Fort III cranofaca dys|uncton) are
requred to treat the orbta, mdfaca, and occusa deformtes.

1tropy and Hypoplasia
The categores of cranofaca atrophy and hypopasa encompass many condtons
such as Perre Robn sequence and Romberg's progressve hemfaca atrophy.
Perre Robn sequence s characterzed by three pathognomonc ndngs:
mcroretrognatha, gossoptoss, and respratory dstress. Perre Robn sequence
may or may not be assocated wth a paata ceft. It s thought by some to occur
secondary to a xed and exed feta head poston that nhbts mandbuar growth
and resuts n mcrognatha. The mcrognatha prevents the natura cauda
mgraton of the tongue from between the cefted paata sheves, and the resutng
deformty as descrbed earer. The functona consequences ncude ntermttent
respratory obstructon and obstructve seep apnea that may ahect feedng,
growth, and safety of the arway. Treatment of a chd mdy ahected wth Perre
Robn sequence may ncude smpy postonng the chd prone unt the chd
"grows out" of the condton. However, f the chd s severey ahected and unabe
to feed adequatey or has an unsafe arway, surgca nterventon s requred. For
decades, tracheotomy was the nta and dentve treatment of choce; however,
today many ntay attempt a tongue-p adheson, treatng the gossoptoss and
aevatng respratory obstructon by suturng the tongue tp to the ower p. The
tongue-p adheson s taken down at the tme of paatopasty. Shoud the tongue-
p adheson not adequatey correct the obstructon, then neonata mandbuar
dstracton can be used to correct the underyng mcroretrognatha and reeve the
obstructve symptoms (Fg. 45-21). Another syndrome of atrophy and hypopasa s
Romberg's progressve hemfaca atrophy, aso known as Parry'"om(erg
syndrome (Fg. 45-22). Romberg's dsease s a dsorder of unknown etoogy,
begnnng n chdhood or adoescence, n whch hemfaca atrophy of the skn,
subcutaneous fat, musce, bone, and cartage progresses for a varabe perod of
tme before spontaneousy ceasng or "burnng out" 2 to 10 years after begnnng.
Most beeve treatment shoud be deayed unt at east 1 year after the process of
atrophy has ceased. Some hematoogsts and oncoogsts have treated the eary
presentaton of Romberg's dsease wth chemotherapy. After the cessaton of
atrophy, reconstructon of the cranofaca skeeton and soft tssues may begn wth
bone and/or cartage grafts, aopastc mpants, derma-fat grafts, fat graftng,
and possby free tssue transfers.
Fg. 45-21.

12 Latera vew of a chd wth Perre Robn sequence and mandbuar
mcroretrognatha. B2 Intraoperatve photo of a submandbuar ncson and pannng
for the pacement of a bured mandbuar dstractor. $2 Latera vew of the chd after
mandbuar dstracton wth sght overcorrecton of retrognatha. The dstractor s
st n pace as evdent from the actvatng rod seen extng the skn retroaurcuary.

Fg. 45-22.

Fronta vew of a chd wth eft-sded Romberg's progressve
hemfaca atrophy.

Hyperplasia> Hypertropy> and 6eoplasia
The categores of cranofaca hyperpasa, hypertrophy, and neopasa encompass
a wde varety of condtons ahectng the cranofaca skeeton. These ncude
vascuar anomaes (dscussed ater n ths chapter), neurobromatoss, hemfaca
hypertrophy, and bony condtons such as osteomas and brous dyspasa. Fbrous
dyspasa can be monostotc, ahectng a snge ocaton, or poyostotc, ahectng
more than a snge ocaton n the skeeton; t may be assocated wth skn
pgmentaton abnormates and endocrne nvovement, and be termed polyostotic
or cCune'$l(right syndrome. Treatment of brous dyspasa of the cranofaca
skeeton ncudes bock resecton and reconstructon wth bone grafts. If extensve
nvovement exsts and bock resecton s not possbe or feasbe, parta resecton
and contourng of the ahected bone s possbe, as ong as there s the
understandng that ong-term outcomes and the behavor of the dsease are
unpredctabe.

7ascular 1no%alies
Vascuar anomaes are vascuar brthmarks that a appear smar: at or rased, n
varous shades of red and purpe.26 For centures, they have been named by
smary coored food and drnk (.e., strawberry hemangoma, port-wne stan).
Today these vascuar brthmarks have been boogcay cassed as ether
hemangiomas or +ascular mal,ormations. The Greek sumx 'oma means "sweng"
or "tumor" and today connotes a eson characterzed by hyperpasa.
Hemangomas are congenta vascuar anomaes that undergo a phase of rapd
growth foowed by sow regresson, based on endothea ce knetcs.
Maformatons are abnorma vascuar channes ned wth quescent endotheum,
usuay are seen at brth, never regress, and have the potenta to expand. The
dherenta dagnoss of vascuar anomaes s routney made by a detaed
accurate hstory and cnca examnaton. For deep esons, radographc studes
may hep determne the dagnoss. Bopsy s used f the dagnoss s uncertan or
there s concern over the potenta of magnancy.

He%angio%as
The nfante hemangoma s the most common brthmark, ahectng 10 to 12% of
whtes, wth a 3-5:1 predecton for femaes and an ncreased ncdence n preterm
nfants (23%) (Fg. 45-23). Hemangomas are sotary n 80% of cases and mutpe
n 20%. In chdren wth mutpe (more than three) cutaneous hemangomas,
abdomna utrasound s suggested to rue out hemangomatoss wth vscera
nvovement. Hemangomas do not cause beedng dsorders; however, more
nvasve esons such as kaposform hemangoendotheoma can resut n
Kassebach-Merrtt syndrome, characterzed by pateet trappng and dsordered
beedng. Hemangomas are usuay rst noted around 2 weeks of fe as a at pnk
spot, often confused wth a superca scratch. Around the second month of fe
they enter the proli,erating phase n whch rapd growth s seen caused by pump,
rapdy dvdng endothea ces. If the hemangoma s superca, the skn
becomes crmson and rased; f the eson s deep, a dark bue or purpe coor s
noted wth ess superca sweng. Hemangoma growth frequenty peeks before
the rst year, and then the esons enter the in+oluting phase n whch growth s
commserate wth the chd. The nvoutng phase s characterzed by dmnshng
endothea actvty and umna enargement. The eson begns to "gray," osng ts
ntense reddsh coor and takng on a purpe-gray shade wth overyng "crepe
paper" skn. The nvouton phase contnues unt 5 to 10 years of age. Regresson
of the eson s then compete. The in+oluted phase begns n 50% of chdren by 5
years of age and n 70% by 7 years. If there was cutaneous uceraton durng the
proferatve phase, a cutaneous scar may persst, aong wth the yeow-gray crepe
paper-ke skn wth bro-fatty deposton. In 50% of chdren, near-norma skn s
restored. The treatment of hemangomas s argey observatona, wth reassurance
of parents that regresson and nvouton w occur. Cutaneous uceraton
secondary to a proferatng hemangoma occurs n 5% of cases and more
frequenty wth p or urogenta esons. Loca wound care, topca appcaton of
docane for pan, and aser cauterzaton may be beneca treatment modates.
Probematc or endangerng hemangomas (.e., perocuar esons threatenng
ambyopa, arway esons, facay dsgurng esons) occur n 10% of cases. The
rst-ne treatment for probematc hemangomas s systemc cortcosterod
therapy, whch s partcuary ehectve (85% response rate). Second-ne therapes
ncude nterferon and vncrstne, each wth ts own attendant ehectveness and
morbdty. Laser therapy has been camed by some to be ehectve n the
treatment of eary hemangomas; however, there has been no concusve proof
that aser therapy ether dmnshes eson buk or nduces nvouton. Laser therapy
has been ehectve n ghtenng ahected skn. Surgery for hemangomas n the
proferatng phase s argey mted to treatment of probematc esons (.e., eyed
esons threatenng ambyopa). Hemangoma surgery usuay s reserved for the
treatment of secondary deformtes and resdua bro-fatty depostons, among
other ndcatons.
Fg. 45-23.

Hemangoma of the ear and retroaurcuar
regon.

7ascular ,al#or%ations
Vascuar maformatons are subcassed by vesse type, such as ymphatc,
capary, venous, or artera, and by rheoogc characterstcs, such as sow ow
and fast ow. Sow-ow esons ncude capary maformatons (CMs) and
teangectasas, ymphatc maformatons (LMs), and venous maformatons (VMs).
Fast-ow esons ncude artera maformatons (AMs) and arterovenous
maformatons (AVMs). In addton, there are combned maformatons. One such
combned eson occurs n Kppe-Trnaunay syndrome n whch CMs, LMs, and VMs
are found and may be assocated wth soft tssue and skeeta hypertrophy n one
or more of the mbs (Fg. 45-24A).
Fg. 45-24.

12 Kppe-Trnaunay syndrome, wth combned vascuar anomay (capary
maformaton, ymphatc maformaton, venous maformaton) of the eg. B2 Sturge-
Weber syndrome, wth V1 and V2 capary maformaton of the eft face. $2
Lymphatc maformaton of the neck, prevousy referred to as cystic hygroma./2
Venous maformaton of the forehead.

CMs are pnk-red macuar vascuar stans that are present at brth and persst
throughout fe. These esons tend to become more verrucous and darker
throughout fe. CMs are ehectvey treated wth a pused-dye aser, and the resuts
often are better wth treatment n nfancy and young chdhood. Laser therapy
often s repettve and proonged. CMs of the head and neck, hstorcay caed
port'0ine stains, may be assocated wth Sturge-Weber syndrome, whch ncudes
vascuar nvovement of the eptomennges and ocuar pathoogy (Fg. 45-24B).

LMs are anomaous ymphatc channes that never regress and have the potenta
to ahect underyng musce and bone, causng sgncant sweng and bony
overgrowth. They have hstorcay been caed lymphangiomas or cystic hygromas
(Fg. 45-24C). LMs can be cassed as mcrocystc, macrocystc, or both. LMs
expand or contract wth the ow of ymph, nfecton, or ntraesona hemorrhage.
Superca LMs that ahect the skn often produce cutaneous vesces that may
coaesce and weep ymph ud. Scerotherapy remans a ma|or treatment modaty
for LMs, and esons that are macrocystc can be asprated before scerotherapy.
Athough surgery rarey removes the entre eson, surgca resecton s the ony
possbty for cure. These resectons often are chaengng, engthy, and assocated
wth sgncant bood oss, and the potenta exsts for regeneraton of ymph
channes and recurrence of the LMs postoperatvey.

VMs are frequenty bush, soft, and compressbe, and swe when dependent (Fg.
45-24D). VMs grow wth the chd, expand sowy, and may enarge durng puberty.
Patents often compan about sthness and pan wth thromboss. VMs can ahect
the skn, musce, and bone. MRI s the modaty of choce for magng these esons.
Preoperatve sceross foowed by surgca extrpaton s the treatment of choce for
VMs that cause functona or appearance-reated dsabty. VMs have the tendency
to recanaze and re-expand. Use of eastc support stockng and ow-dose asprn
therapy are mportant ad|unctve treatment modates for VMs nvovng the egs.

Pure AMs are rare and more commony present as AVMs. AVMs appear as red
voaceous skn wth a papabe mass beneath. Loca warmth, brut, and thr are
frequenty present. AVMs have the key consequences of schemc changes,
uceraton, ntractabe pan, and ntermttent beedng. The natura hstory of AVMs
has been descrbed as consstng of four stages: quescence, expanson,
destructon, and decompensaton. Usuay, treatment for AVM s ntated when
sgns and symptoms of schemc pan, uceraton, beedng, or hemodynamc
nstabty (stages 3 and 4) are evdent. Surgca treatment ncudes artera
embozaton to temporary occude the ndus 24 to 72 hours before surgca
extrpaton. The ndus and overyng ahected skn must be wdey excsed, and
reconstructon can be performed afterward.

$ongenital ,elanocytic 6e+i
Congenta meanocytc nev (CMNs) contan nevus ces and are usuay present at
brth. Lesons are frequenty ght to dark brown and round or ova, and vary greaty
n sze, pattern, and anatomc ocaton. The most common ocaton of CMNs s the
trunk, foowed by the extremtes and head and neck. Frequenty, arger esons
are assocated wth mutpe smaer satete esons. Over tme, these esons may
become ess (or sometmes more) pgmented and deveop hypertrchoss and a
varegated texture, ncudng noduarty. Sma CMNs are <1.5 cm n dameter, and
arge ones are >10 cm. Gant CMNs usuay are >20 cm n ther greatest dmenson
n aduthood, and ths correates wth a 9-cm scap eson or a 6-cm trunk eson n
an nfant. A CMNs shoud be montored for worrsome changes that ndcate the
need for bopsy, ncudng uceraton, uneven pgmentaton, change n shape, and
noduarty. There s controversy over the actua ncdence of magnant
transformaton of CMNs; however, most experts beeve that meanoma may arse
drecty from a CMN. No convncng study to date has proven that excson of a
CMN reduces the rate of magnant transformaton to meanoma; however, many
cncans fee that excson serves at east to debuk the eson. The reported
fetme rsk for meanoma arsng n sma or arge CMNs s between 0 and 5%; the
rsk for gant CMNs s estmated to be between 5 and 10%.27 In addton to beng
at rsk for meanoma, patents wth arge or gant CMNs are at rsk for
neurocutaneous meanocytoss (eptomenngea meanoss), and ths condton
ncudes coectons of meanocytes n the eptomennges. Neurocutaneous
meanocytoss carres a fetme nonreducbe rsk of centra nervous system
meanoma and other morbdty and mortaty from sezures, hydrocephaus, and
other centra nervous system condtons. MRI screenng for nfants born wth arge
or gant CMNs s recommended to make the dagnoss of neurocutaneous
meanocytoss.

Many dherent treatments have been advocated for the chd wth CMN; however,
the overwhemng goas are to remove (or at east reduce) the rsk of magnant
transformaton, preserve functon, and mprove cosmess. Dermabrason, chemca
pees, and aser therapy have been reported to mprove the appearance; however,
none of these modates competey removes nevus ces. To address magnant
potenta, ony compete excson s a possbe souton, and ths s dmcut, because
nevus ces may extend beyond the skn and nto the deep subcutaneous tssue
and even the underyng musce. The surgca optons ncude drect excson and
prmary cosure, sera excson, excson and skn graftng, and staged tssue
expanson wth subsequent eson excson and ap reconstructon (Fg. 45-25).
Treatment optons have partcuar ndcatons wth respect to the ocaton of the
nevus. Scap esons are best treated wth tssue expanson. Fu-thckness skn
graftng s best used for ear and eyed reconstructon. Tssue expanson s
assocated wth ncreased morbdty n ower extremty reconstructon, and
therefore excson and graftng, even wth prevousy expanded fu-thckness skn
grafts, s often the treatment of choce. In summary, CMNs often are treated
surgcay to decrease the rsk of magnant degeneraton to meanoma as we as
to correct the sgncant appearance-reated deformty.
Fg. 45-25.

12 Congenta meanocytc nevus (CMN) of the posteror shouder. B2 Treatment of
CMN of the posteror shouder wth tssue expanson. $2 Appearance of the posteror
shouder after remova of tssue expanders, excson of the CMN, and ap coverage.

4econstructi+e Surgery
0acial 4econstruction a#ter 0racture
General Principles
As technoogc advances rase the eve of energy nvoved n modern systems of
transportaton, recreaton, and weaponry, so foow ncreases n the degree of
maxofaca destructon reated to msadventures wth ths technoogy. The rst
phase of care for the patent wth maxofaca trauma s actvaton of the
advanced trauma fe support protoco. Concomtant n|ures beyond the face are
the rue rather than the excepton. The most common fe-threatenng
consderatons n the faca trauma patent are arway mantenance, contro of
beedng, dentcaton and treatment of aspraton, and dentcaton of other
n|ures. Once the patent's condton has been stabzed and fe-threatenng
n|ures treated, attenton s drected to dagnoss and management of cranofaca
n|ures.

Physca examnaton of the face wth attenton to aceratons, bony step-ohs,
nstabty, tenderness, ecchymoss, faca asymmetry, and deformty gudes the
examner to underyng hard tssue n|ures. Tradtona specazed radography has
argey been repaced by wdey avaabe hgh-resouton CT. Corona, sagtta, and
three-dmensona reconstructons of mages further eucdate compex n|ures.

,andible 0ractures
Mandbuar fractures are common n|ures that may ead to permanent dsabty f
not dagnosed and propery treated. The mandbuar ange, ramus, coronod
process, and condye are ponts of attachment for the musces of mastcaton,
ncudng the masseter, temporas, atera pterygod, and meda pterygod
musces (Fg. 45-26). Fractures are frequenty mutpe, and dsturbances n denta
occuson reect the forces of the many musces of mastcaton on the fracture
segments. Denta occuson s perhaps the most mportant basc reatonshp to
understand about fracture of the mdface and mandbe. The Ange casscaton
system descrbes the reatonshp of the maxary teeth to the mandbuar teeth.
Cass I s norma occuson, wth the mesa bucca cusp of the rst maxary moar
ttng nto the ntercuspa groove of the mandbuar rst moar. Cass II
maoccuson s characterzed by anteror (mesa) postonng, and cass III
maoccuson s posteror (dsta) postonng of the maxary teeth wth respect to
the mandbuar teeth (Fg. 45-27).
Fg. 45-26.

Mandbuar anatomy.
(Reproduced wth permsson from Thornton |, Hoer L: Faca fractures II: Lower
thrd. Selected "eadings Plast Surg 9:1, 2002.)

Fg. 45-27.

Ange casscaton. Cass I: The mesa bucca cusp of the maxary rst moar ts
nto the ntercuspa groove of the mandbuar rst moar. Cass II: The mesa bucca
cusp of the maxary rst moar s mesa to the ntercuspa groove of the
mandbuar rst moar. Cass III: The mesa bucca cusp of the maxary rst moar s
dsta to the ntercuspa groove of the mandbuar rst moar.
(Reproduced wth permsson from Thornton |, Hoer L: Faca fractures II: Lower
thrd. Selected "eadings Plast Surg 9:1, 2002.)

Nonsurgca treatment may be used n stuatons n whch there s mnma to no
dspacement, preservaton of the pretraumatc occusve reatonshp, and norma
range of moton. The goas of surgca treatment ncude restoraton of
pretraumatc denta occuson, reducton and stabe xaton of the fracture, and
repar of soft tssue. Operatve repar nvoves seatng of the condyes wthn the
genod fossa, achevement of maxary-mandbuar xaton wth arch bars or
ntermaxary screws to estabsh proper denta occuson, and ntraora, extraora,
or combnaton surgca exposure of fracture nes. The mandbuar patng
approach foows one of two schoos of thought: rgd xaton as espoused by the
Assocaton of Interna Fxaton group (AO/ASIF) and ess rgd but functonay
stabe xaton (Champy technque). Regardess of the stabzaton approach, one
of the postoperatve ob|ectves s reease from maxary-mandbuar xaton and
resumpton of range of moton as soon as possbe to mnmze the rsk of
ankyoss. Other potenta compcatons ncude nfecton, nonunon, maunon,
maoccuson, faca nerve branch n|ury, nfra-aveoar or menta nerve n|ury, and
denta fractures.

?rbital 0ractures
Treatment of a but the smpest orbta n|ures shoud ncude evauaton by an
eye specast to assess vsua acuty and rue out gobe n|ury. Orbta fractures
may nvove the orbta roof, oor, or atera or meda was. The most common
orbta fracture s the orbta oor bow-out fracture caused by drect pressure to
the gobe and sudden ncrease n ntraorbta pressure. Because the meda oor
and nferor meda wa are made of the thnnest bone, fractures occur most
frequenty at these ocatons. These n|ures may be treated expectanty f they are
sumcenty sma and wthout compcaton. However, arger bow-out fractures and
those assocated wth enophthamos (ncreased ntraorbta voume), entrapment of
nferor orbta tssues (dagnosed va the forced ducton test), or dpopa astng
>2 weeks generay requre surgca treatment.28 There are many approaches to
the orbta oor, ncudng the transcon|unctva, subcary, and ower
bepharopasty ncsons. A provde access to the orbta oor and aow for repar
wth a muttude of dherent autogenous and synthetc materas. Late
compcatons ncude persstent dpopa, enophthamos, ectropon, and entropon.

Latera and nferor orbta rm fractures aso are not uncommon and are often
assocated wth the zygomatcomaxary compex fracture pattern, as dscussed
ater.

Speca menton shoud be made of two uncommon compcatons after orbta
fracture. Superor orbta ssure syndrome resuts from compresson of structures
contaned n the superor orbta ssure n the posteror orbt. These ncude crana
nerves III, IV, and VI, and the rst sensory dvson of crana nerve V. Compresson
of these structures eads to symptoms of eyed ptoss, gobe proptoss, parayss of
the extraocuar musces, and anesthesa n the crana nerve V1 dstrbuton. If the
optc nerve (crana nerve II) s aso nvoved, symptoms ncude bndness and the
syndrome s dubbed or(ital apex syndrome. Both of these syndromes are medca
emergences, and sterod therapy or surgca decompresson s consdered.

"ygo%a and "ygo%atico%a8illary $o%ple8 0ractures
The zygoma forms the atera and nferor borders of the orbt. It artcuates wth
the sphenod bone n the atera orbt, the maxa meday and nferory, the
fronta bone superory, and the tempora bone ateray (Fg. 45-28). Zygoma
fractures may nvove the arch aone or many of ts bony reatonshps. Isoated
arch fractures manfest as a attened, wde face wth assocated edema and
ecchymoss. Nondspaced fractures may be treated nonsurgcay, whereas
dspaced and commnuted arch fractures may be reduced and stabzed ndrecty
(Ges approach) or, for more compcated fractures, drecty through a corona
ncson.
Fg. 45-28.

Faca bone anatomy.
(Reproduced wth permsson from Hoer
et a.28)

The zygomatcomaxary compex (ZMC) fracture nvoves dsrupton of the
zygomatc arch, the nferor orbta rm buttress, the zygomatcomaxary buttress,
the atera orbta wa, and the zygomatcofronta buttress. The fracture segment
tends to rotate ateray and nferory, creatng an expanded orbta voume, mted
mandbuar excurson, an nferor cant to the papebra ssure, and a attened
maar emnence. ZMC fractures are amost aways accompaned by numbness n
the nfraorbta nerve dstrbuton and subcon|unctva hematoma. Dspaced
fractures are treated by exposure through mutpe ncsons to gan access to a of
the buttresses requrng xaton. These ncude the upper eyed ncson
(zygomatcofronta buttress and atera orbta wa), the subtarsa or
transcon|unctva ncson (orbta oor and nfraorbta rm), and the maxary
gngvobucca sucus ncson (zygomatcomaxary buttress). Agan, sgncanty
compex zygomatc fractures requre wde exposure through a corona approach.5

6aso-?rbital-3t%oid 0ractures
Naso-orbta-ethmod (NOE) fractures are often part of a consteaton of panfaca
fractures and ntracrana n|ures. Anatomcay, the fracture pattern nvoves the
meda orbts, nasa bones, nasa processes of the fronta bone, and fronta
processes of the maxa. These n|ures resut n severe functona dect and
cosmetc deformty from coapse of the nose, ethmods, and meda orbts;
dspacement of meda cantha gament xaton; and nasoacrma apparatus
dsrupton. Teecanthus s produced by spayng apart of the nasomaxary
buttresses to whch the meda cantha gaments are attached. Treatment typcay
nvoves patng or wrng a bone fragments metcuousy, potentay wth prmary
bone graftng, to restore ther norma conguraton. Key to the successfu repar of
an NOE fracture s the carefu re-estabshment of the nasomaxary buttress and
restoraton of the pretrauma xaton ponts of the meda cantha gaments. If
commnuton s severe, ths may be achevabe usng transnasa wrng of the
gaments.

0rontal Sinus 0ractures
The regon of the fronta snus s a reatvey weak structura pont n the upper
face. For ths reason, t s a common ocaton for fracture n faca trauma. The
pared snuses each have an anteror bony tabe that determnes the contour of the
forehead and a posteror tabe that separates the snus from the dura. Each snus
drans through the meda oor nto ts frontonasa duct, whch emptes nto the
mdde meatus wthn the nose. Treatment of a fronta snus fracture depends on
the fracture characterstcs (Fg. 45-29).
Fg. 45-29.

Agorthm for the treatment of fronta snus fracture. CSF = cerebrospna ud; CT =
computed tomography; NF = nasofronta; ORIF = open reducton, nterna xaton.

6asal 0ractures
The nose s the most common faca fracture ste due to ts promnent ocaton, and
such fracture can nvove the cartagnous nasa septum, the nasa bones, or both.
It s mportant to perform an ntranasa examnaton to determne whether a septa
hematoma s present. If present, a septa hematoma must be ncsed, draned, and
packed to prevent pressure necross of the nasa septum and ong-term mdvaut
coapse. Cosed reducton of nasa fractures may be performed under oca or
genera anesthesa. Unfortunatey, many, f not most, show some deformty upon
na heang, requrng rhnopasty f arway obstructon s present or f mproved
appearance s desred.

Pan#acial 0ractures
Fractures of mutpe bones n varous ocatons fa nto the category of panfaca
fracture. These may nvove fronta and maxary snus fractures, NOE fractures,
orbta and ZMC fractures, paata fractures, and compex mandbe fractures. The
dmcuty n the repar of these n|ures es not n the technca aspects of xaton
but n the re-estabshment of norma reatonshps between faca features n the
absence of a pretraumatc reference ponts. Wthout proper correcton of bony
fragment reatonshps, faca wdth s exaggerated and faca pro|ecton s ost. The
key pont n approachng the patent wth a panfaca fracture s rst to reduce and
repar the zygomatc arches and fronta bar to estabsh the frame and wdth of the
face. The nasomaxary and zygomatcomaxary buttresses may then be repared
wthn ths correct frame. Next, the maxa may be reduced to ths framework,
foowed by paata xaton f needed. Fnay, now that the mdface reatonshps
have been corrected, maxary-mandbuar xaton can be apped wth the
mandbe n correct occuson foowed by patng of any mandbuar fractures.29

3ar 4econstruction
Acqured defects of the aurce have many causes, and many dherent choces for
reconstructon are avaabe. Reconstructve approach often s determned by the
sze and ocaton of the defect. Sma heca esons may be smpy excsed as a
wedge and cosed prmary. Larger defects of the upper and mdde thrds of the
ear may use antheca and concha cartage reducton patterns to reduce the
crcumference of the hex to aow prmary cosure. When heca defects are too
arge for ths souton, oca aps may be used to cose or re-create the mssng
tssue. Postaurcuar aps created n staged procedures may be manpuated to
create a skn tube mmckng the fured hex and brdgng the gap of a defect.
Aternatvey, use of an Anta-Buch chondrocutaneous advancement ap combned
wth cartagnous reducton aows for cosure of defects30 (Fg. 45-30). Even arger
defects of the upper and mdde thrds of the ear may be reconstructed wth arge
oca skn aps combned wth contraatera cartage grafts or contraatera
composte grafts. Athough ear obe defects are reatvey smpe to cose prmary,
ower thrd aurcuar defects that nvove more than |ust the obe are compex and
requre cartagnous support, often combned wth oca skn aps.
Fg. 45-30.

Moded Anta-Buch ear reconstructon. 12 Superor hex eson. B2 Excson pattern
and reconstructon markngs. $2 Defect, ap eevaton, and cartage reducton. /2 V-
Y advancement of the ap. 32 Fap nsettng. 02 Appearance at 1 month after surgery.
(Photographs reproduced wth permsson from M. Gmbe.)

6asal 4econstruction
Reconstructon of the nose requres apprecaton of the nne aesthetc subunts that
are dened by norma anatomc contours and ghtng patterns (Fg. 45-31). In
genera, f a defect nvoves >50% of a subunt, the remander of the subunt
shoud be excsed and ncuded n the reconstructon. The nose can be thought of
as beng composed of three ayers: skn cover, structura support, and mucosa
nng. When a defect or antcpated defect s evauated, t s usefu to consder
what ayers of tssue w be mssng so that a reconstructon can be devsed that
repaces each ayer. Nasa reconstructon methods draw on the fu arsena of
reconstructve technques. Heang by secondary ntenton s successfuy used n
concavtes such as the aar groove. Spt- or fu-thckness skn grafts may be used
for superca defects of the nasa dorsum or sdewa. Composte grafts may be
used for the nasa tp or aar rm (see Fg. 45-3). Loca random pattern aps are
usefu n cosng sma defects of the dorsum and tp, and may be combned wth
cartage grafts f structura support s needed. Axa pattern aps are commony
used for arger defects. These aps have the advantage of beng abe to cover and
revascuarze underyng cartage grafts and en|oy a cose coor match to
surroundng skn. Workhorse aps often used n nasa reconstructon ncude the
nasoaba ap and the paramedan forehead ap (Fg. 45-32). Even arger defects
may requre scapng aps or free rada forearm aps. Spt cavara cantever
bone grafts may provde the nasa dorsum support. Lnng s generay acheved
wth scar tssue turnover aps, mucoperchondra aps from wthn the nasa
vestbue, or skn graftng of the undersde of transposed aps.
Fg. 45-31.

Nasa aesthetc subunts.
(Photograph reproduced wth permsson from M.
Gmbe.)

Fg. 45-32.

Nasa reconstructon wth axa pattern aps. Top ro02 Nasoaba ap reconstructon
of an aar defect. !ottom ro02 Paramedan forehead ap reconstructon of the nasa
obue.
(Photographs reproduced wth permsson from M. Gmbe.)

Lip 4econstruction
The ps are mportant for artcuate speech, eatng and mantenance of ora
competence, faca expresson, and aesthetc harmony of the ower face. Three
ayers of tssue form the upper and ower ps: skn, musce, and mucosa. Bood
suppy s through the faca artery and ts branches to the p, the superor and
nferor aba arteres. Lp defects can arse from trauma, burns, neopasms,
congenta esons, cefts, or nfecton. The most common magnancy n the upper
p s basa ce carcnoma, and the most common n the ower p s squamous ce
carcnoma. As wth amost a types of reconstructon, choce of technque s
heavy dependent on defect sze, ocaton, and decent structures. The goas of
p reconstructon are restoraton of the competent ora sphncter wth vermon
apposton, preservaton of sensaton, and avodance of mcrostoma, a whe
preservng a near-norma statc and dynamc appearance. In the upper and ower
p, vermon-ony defects can be corrected wth advancement of the aba
mucosa, often caed a lip sha+e. In defects of ess than one thrd the horzonta
ength, enough redundancy s present to aow prmary cosure. More compex
decsons must be made for defects that are between one thrd and two thrds of
the tota p ength. The two categores of p ap technque are transora cross-p
aps and crcumora advancements aps. Cross-p aps ncude the Abb ap and
the Estander ap. The Abb ap was orgnay desgned to reconstruct centra
upper p (tuberce) defects wth ower p fu-thckness tssue vascuarzed by one
of the aba arteres (Fg. 45-33). The technque requres a second-stage procedure
for dvson of the pedce. The Estander ap s smar n prncpe but s based
ateray at the ora commssure and s used to reconstruct atera upper or ower p
esons. Both the Estander and Abb aps are denervated, but sensaton and
perhaps even motor functon return over months.31 The Karapandzc technque s
an advancement-rotaton ap technque desgned for centra ower p defects.
Athough good functon, sensaton, and mobty are preserved, a sde ehect s
reducton n the sze of the ora aperture. The Webster-Bernard technque uses
cheek tssue advancement aps to repace defects wth fu-thckness or parta-
thckness cheek ncsons extended ateray from the commssure (Fg. 45-34).
When performed bateray, both the Karapandzc and the Webster-Bernard
methods can be used to reconstruct a compete upper or ower p.
Fg. 45-33.

Abb ap upper p reconstructon. 12 Defect and ap desgn. B2 Rotaton of the ap
and prmary cosure of the donor ste. $2 Dvson of the pedce (after 2 to 3 weeks)
and na nsettng.

Fg. 45-34.

Webster-Bernard p reconstructon technque.
(Reproduced wth permsson from Cosmann ||, Pogre A, Schmdt BL: Reconstructon
of perora defects foowng resecton for ora squamous ce carcnoma. 3 /ral
axillo,ac Surg 64:367, 2006. Copyrght Esever.)

In addton, mcrovascuar free tssue transfer reconstructon may be necessary n
cases where there s no remanng p. The rada forearm free ap s the most
commony used for ths purpose, usuay transferred wth the pamars ongus
tendon for p support.

3yelid 4econstruction
The eyeds protect the eye from exposure and are another cruca aesthetc
structure of the face. They consst of an anteror amea (skn and orbcuars ocu
musce) and a posteror amea (tarsus and con|unctva). The eyed bood suppy s
robust, and schema s rarey a concern n reconstructon.

=pper 3yelid
Defects comprsng <25% of the upper eyed can generay be cosed prmary n
pentagona approxmatng fashon (Fg. 45-35). For defects nvovng 25 to 50% of
the upper eyed, atera canthotomy (reease of the atera cantha tendon) and
canthoyss (reease of the superor mb of the atera papebra tendon) can be
performed to aow advancement and are often combned wth use of a atera
semcrcuar ap (Fg. 45-36). Defects arger than 50% of the upper eyed may be
reconstructed wth a Cuter-Beard fu-thckness advancement ap or a moded
Hughes tarsocon|unctva advancement ap (Fg. 45-37).
Fg. 45-35.

Upper eyed defect of <25%. Prmary cosure.
(Reproduced wth permsson from Pham RT: Reconstructon of the upper eyed.
/tolaryngol Clin #orth $m 38:1023, 2005. Copyrght Esever.)

Fg. 45-36.

Upper eyed defect of 25 to 50%. 12 Latera canthotomy. B2 Semcrcuar ap.
(Reproduced wth permsson from Pham RT: Reconstructon of the upper eyed.
/tolaryngol Clin #orth $m 38:1023, 2005. Copyrght Esever.)

Fg. 45-37.

Upper eyed defect of >50%. 1 and B2 Cuter-Beard fu-thckness ower eyed
advancement ap. $ and /2 Hughes ower eyed tarsocon|unctva advancement
ap.
(Reproduced wth permsson from Pham RT: Reconstructon of the upper eyed.
/tolaryngol Clin #orth $m 38:1023, 2005. Copyrght Esever.)

Lo!er 3yelid
Lower eyed reconstructon consderatons parae those for the upper eyed. In
addton, speca attenton must be gven to the preventon of scera vsbty and
ectropon, whch can arse from excessve vertca tenson due to ether technque
or scarrng. Smar reconstructve methods may be used, ncudng drect cosure,
semcrcuar aps and cantha reease, and advancement aps. Grafts may aso be
used f the defect s parta thckness. Fu-thckness contraatera upper eyed skn
grafts are sutabe for repacng the anteror amea. The posteror amea requres
sturdy, nonkeratnzed graft tssue, such as cartage (tarsa, ear, or nasa septa) or
hard paate mucosa grafts, to aow gobe apposton.32

Ptosis
In the norma eyed, the orbcuars ocu musce, Mer's musce, and evator
papebrae musce act n concert to open and cose the papebra aperture and to
mantan the eve of the upper eyed wth respect to the pup. Eyed ptoss s
created by derangement of ths cooperatve acton. Ptoss may be congenta or
acqured. Congenta ptoss s caused by d anomaes, ophthamopega, and
synkness, whereas acqured ptoss can be neurogenc, myogenc, or traumatc n
nature. Horner's syndrome s a form of neurogenc ptoss caused by nterrupted
sympathetc nnervaton that eads to ptoss, moss, and anhydross. A thorough
evauaton of the ptotc patent ncudes a genera eye and vsua acuty
examnaton, attenton to sgns of exposure or rrtaton, measurement of margna-
reex dstance, observaton of the heght of the supratarsa fod, and assessment
of evator functon. Severty of ptoss and degree of evator dysfuncton are crtca
n decdng the approprate correctve procedure (Tabe 45-11). Md ptoss may be
addressed wth the Fasanea-Servat procedure, whch nvoves excson of the
superor tarsa edge, con|unctva, and evator aponeuross, and muerectomy.
Other correctons of md ptoss usuay nvove varatons on ths procedure.
Moderate ptoss wth far to good evator functon may be treated wth some form
of a evator aponeuross shortenng procedure. Severe ptoss wth poor evator
functon requres use of an aternate eyed motor. The frontas musce fasca sng
technque, whch uses strps of fasca grafts sutured to the frontas musce, s one
such souton.

Table 45-11 3yelid Ptosis
$lassi.cation

Casscaton of ptoss
severty

Md 1-2 mm
Moderate 3 mm
Severe 4+ mm
Casscaton of evator
functon

Exceent 12-15 mm
Good 8-12 mm
Far 5-7 mm
Poor 2-4 mm

Skull and Scalp 4econstruction
Scalp 4econstruction
The scap s formed of ve ayers: Skn, subCutaneous tssue, gaea $poneurotca,
Loose areoar tssue, and Percranum (SCALP). The scap s we vascuarzed
bateray by branches of the externa carotd artery, ncudng the superca
tempora arteres, the occpta arteres, and the posteror aurcuar arteres. In
addton, the batera supraorbta and supratrochear arteres contrbute to the
forehead and anteror scap bood suppy. These vesses run n the subcutaneous
tssue ayer, |ust superca to the gaea. Because of ths rch bood suppy, scap
aceratons can ead to dramatc bood oss, an event that usuay can be curtaed
by a smpe runnng/ockng suture cosure.

Parta-thckness scap oss due to trauma usuay occurs at the eve of the oose
areoar tssue pane and s treated ntay wth dbrdement of devtazed tssue. If
a parta-thckness defect s sma enough, prmary cosure or skn graft can be
used. Athough the cosmetc resut s often ess than desrabe, a ayers of the
scap w accept a skn graft, ncudng the cavara f t s burred down to ts dpo.
Grafted areas may be reconstructed ater wth har-bearng scap skn through the
use of aps or tssue expanson. Because the scap s reatvey neastc, scorng of
the gaea ayer often factates cosure of fu-thckness defects, but care must be
taken to avod aceratng the bood vesses |ust superca to the gaea. Larger
areas of oss (4 to 8 cm) may be covered wth arge scap aps, as casscay
descrbed by Ortcochea.33 Graftng of defects or donor stes eaves a vsbe area
of aopeca. Tssue expanson has been very successfu n repacng scarred or
grafted regons wth har-bearng skn. Defects arger than 8 to 10 cm are best
treated wth mcrosurgca free tssue transfer. Tota or subtota scap avusons are
rare n|ures that usuay occur when a person's ong har becomes caught n
rotatng machnery. These potentay devastatng n|ures are deay treated by
scap repantaton, because the avused segment usuay has preserved vesses
(Fg. 45-38).
Fg. 45-38.

Twenty-ve-year-od woman wth 70% scap avuson after a pedestran-automobe
accdent. Top ro02 Defect and specmen ntraoperatvey. !ottom ro02 Appearance 9
weeks after mcrosurgca scap repantaton.
(Photographs reproduced wth permsson from M. Gmbe.)

$al+arial 4econstruction
Autogenous bone remans the matera of choce for reconstructon of sku defects.
Its advantages ncude resstance to nfecton and abty to hea wth strength. A
autogenous bone sources have the dsadvantage of donor ste morbdty. Bone
grafts can be harvested from a norma area of the cavara, of whch the outer tabe
may be used as a graft for defects of mted sze. Care must be taken durng
harvest to avod compromse of the nner tabe. Rb bone may aso be used, ether
as a spt-rb graft or as a mcrosurgca free osseous ap. Unfortunatey, use of rbs
to reconstruct the sku may gve an unappeang "washboard" appearance to the
scap. Another dsadvantage of bone grafts, athough not aps, s graft resorpton
over tme.

Aternatve materas to autogenous bone exst for cavara reconstructon,
ncudng methy methacryate, ttanum, and hydroxyapatte (wth or wthout bone
morphogenc proten). Athough they have the advantage of no donor ste, these
pastcs and metas are assocated wth a hgher rsk of nfecton necesstatng
remova. Varous formuatons of cacum phosphate hydroxyapattes are beng
actvey studed as bone repacement materas.

Head and 6eck 4econstruction
The head and neck regon has a compact arrangement of crtca and compex
structures encasng the essenta access routes to the GI and respratory systems.
The tssues of the face, mouth, and cavtes serve as a prmary communcaton
nterface wth the externa envronment through faca and verba expresson.
Therefore, cancer resectons wth adequate safety margns can be severey and
mutpy debtatng. The management of head and neck cancer patents demands
an ntegrated mutdscpnary team approach that ncudes the sks of abatve
and reconstructve surgeons, medca and radaton oncoogsts, pathoogsts,
nutrtonsts, and functona and psychoogc rehabtaton specasts.

Tu%or-1blati+e Surgery
The freedom avaabe to the abatve surgeon to competey excse a tumor s
mted, at east party, by the capabty of the reconstructve surgeon to restore
anatomc contnuty and acheve successfu wound heang. A neck dssecton to
remove cervca ymphatcs and nodes may be performed for prophyactc or
curatve ntent, for more accurate prognostcaton by operatve stagng, and/or for
sodcaton of pans for ad|unctve treatments. It s mportant to be famar wth
the tumor, nodes, and metastases (TNM) casscaton and stagng of head and
neck cancers. The N and M parameters are fary constant for most head and neck
cancers, whereas the T parameter vares accordng to tumor ocaton.

Principles o# 4econstruction
The reconstructve surgeon ams to restore ost anatomc components adequatey.
Resdua dects, seemngy nconsequenta, may progress to psychoogc
morbdty, soceta maacceptance, and soca wthdrawa. Uncompcated and
tmey wound heang s mportant to aow radotherapy when ndcated and
smooth dscharge to home and occupaton.

Each defect can be addressed by a number of methods, but the technque must be
decded for each ndvdua patent. Athough a more compex reconstructon mght
oher mproved outcomes, t may brng an ncreased rsk of compcatons. Some
patents may therefore benet from use of a smper method wth more acceptabe
anesthetc and operatve rsk rather than a god-standard reconstructon. Such an
approach may be approprate, for exampe, for an edery patent wth an advanced
T4 cancer and short fe expectancy. Reconstructon s mpossbe for some
functona osses, such as the enuceaton of an eye, but repacement by a
reasonaby aesthetc prosthess may be achevabe.34

4econstructi+e ?ptions by 4egion
Before the 1970s, autogenous tssue reconstructons were argey restrcted to
oca or regona pedced aps, ncudng the trapezus, pectoras, and
detopectora workhorse aps. Wth mcrovascuar free tssue transpantaton,
defects that were prevousy deemed neary mpossbe to reconstruct can now be
addressed n a snge operaton. Consequenty, head and neck cancers that were
hstorcay unresectabe have become more operabe.

Intraoral Structures
The reconstructve choce for mouth oor, tongue, and other ntraora defects s
dctated by the dmenson of the defect, the voume of tssue ost, and resdua
tongue mobty. The tongue and ad|acent mucosa surfaces hea exceptonay we,
so sma defects may be treated by prmary cosure or even eft to hea
spontaneousy. Smaer defects, ess than one fourth gossectomy, may be treated
wth a skn graft or perhaps prmary cosure f tongue mobty s preserved. Larger
defects, more than one thrd gossectomy, ca for reconstructon by free tssue
transfer, commony a free rada forearm or anteroatera thgh ap for smaer- or
arger-voume defects, respectvey. Tota gossectomy defects are a ma|or
chaenge, and there exsts no dea method to restore tongue motor functons. The
prmary goa s to protect the arway from aspraton. Swaowng and artcuaton
are often suboptma after tota gossectomy reconstructons. Optons ncude
buker myocutaneous free aps harvested from the anteroatera thgh, the back
(atssmus dors), or the abdomen (rectus abdomns), or pedced regona aps
(e.g,. atssmus dors).35

The reconstructve choce for other ntraora soft tssue defects shoud aso take
nto consderaton the specc characterstcs of the defect, such as ts thckness
and dmensons, and nvovement of the ora commssure, faca skn, and/or neck.
Bucca defects, for exampe, may be adequatey treated wth a rada forearm free
ap or a thn anteroatera thgh ap. Thcker defects may be more appropratey
reconstructed wth a fascocutaneous anteroatera thgh free ap. Those that
extend through the fu thckness of the cheek to nvove the externa faca skn
may be reconstructed wth a cutaneous or myocutaneous anteroatera thgh free
ap that has been foded to address the nterna mucosa, externa skn, and
ntervenng soft tssue defects smutaneousy.36 When the contour of the neck s
sunken and asymmetrc after a neck dssecton, t s possbe to mprove symmetry
by nsettng part of the ap nto the neck. Ths maneuver aso obterates dead
space and heps protect the ad|acent ma|or neurovascuar structures.

,andible and ,id#ace
Mandbuar defects may arse from the abaton of tumors nvovng the bone tsef
or from the need to satsfy cearance margns for ad|acent soft tssue tumors.
Segmenta mandbuar defects can be cassed as soated bone defects,
compound defects (bone and ora nng or skn), composte defects (bone, ora
nng, and skn), or extensve composte defects (bone, ora nng, skn, and soft
tssues).37 The prmary goas of mandbuar reconstructon are to restore bony
contnuty, mastcatory (wth accurate denta occuson) and speech functons, and
faca contour, and to mantan tongue mobty. Eary mandbuar reconstructons
nvoved the use of varous prosthetc materas, wth or wthout conventona bone
grafts, and accompanyng oca or regona soft tssue aps. Athough sma
segmenta defects are st reconstructbe usng autogenous bone grafts, they are
not vascuarzed and therefore may fa, especay f radotherapy s admnstered.
The best opton for most mandbuar defects s the bua bone free ap wth an
ad|oned skn sand supped by reabe septocutaneous vesses (occasonay
muscuocutaneous perforators) from the peronea artery and ven; ths s termed a
4(ula osteoseptocutaneous ,ree %ap (Fg. 45-39).38 Its many desrabe
characterstcs ncude (a) the abty to wthstand mutpe osteotomes (as ong as
the perostea bood suppy s not nterrupted) so that the bone can be foded to re-
create the contour of any mandbuar regon, (b) an unmatched suppy of sturdy
bone ength (22 to 26 cm n the adut) sumcent to reconstruct even ange-to-ange
mandbuar defects, (c) a bcortcocanceous structure that can toerate the
ncorporaton of osseontegrated denta mpants, (d) acceptabe donor ste
morbdty when the ap s appropratey harvested, and (e) a donor ste ocaton
that aows a two-team approach for smutaneous tumor abaton and ap
harvest.39,40 Reasonabe aternatves ncude vascuarzed bone aps from the
ac crest, radus, or rbs. Extensve composte mandbuar defects may demand
more than one free ap (such as one anteroatera thgh free ap wth one bua
osteoseptocutaneous free ap) to reconstruct the entre anatomy n one
operaton.41 These prncpes are aso appcabe to other bony defects n the head
and neck regon, ncudng maxary and other mdfaca defects. The goas of
mdface reconstructon ncude the restoraton of faca contour and pro|ecton,
achevement of accuratey occusve maxary dentton, provson of approprate
nfraocuar support, and seaed separaton of ad|acent nasa and ora cavtes.
Fg. 45-39.

Soft tssue and bony reconstructon of a compound segmenta mandbuar defect
usng a bua osteoseptocutaneous free ap. 12 Squamous ce carcnoma seen
arsng from the eft bucca mucosa. B2 Compound segmenta eft mandbuar defect
resutng from wde oca excson of the neopasm, whch nvaded the bone and oca
soft tssues. $2 Fbua osteoseptocutaneous free ap; the pedce artery (red arro0s),
pedce ven ((lue arro0s), and osteotomy ste (yello0 arro0) are ndcated. /2 After
contourng and mnpate xaton, the bua osteoseptocutaneous free ap was nset
nto the eft mandbuar defect, wth the skn padde used to reconstruct the ntraora
soft tssues. 3 and 02 Four months after reconstructon the patent had good mouth
openng and good cosmess; note the skn padde of the free ap vsbe ntraoray.

3sopagus and Hypoparyn8
The goas of reconstructon for esophagea and hypopharyngea defects, whch
may be crcumferenta or parta, are to mantan umna patency, restore speech
and swaowng, and avod strctures, stuas, and GI anastomotc eaks.
Reconstructve optons for parta defects ncude prmary cosure, f umna
narrowng s nsgncant, and skn (or derma) grafts for parta-nng defects. A
regona musce ap may be usefu for patchng sma fu-thckness defects, but
arger defects ca for free tssue transfer of a |e|una ap or a tubed
fascocutaneous ap.42 The |e|una ap procedure was the rst successfu free
tssue transfer n humans, performed n 1957 for reconstructon of the cervca
esophagus. It has snce become a robust opton for ths purpose. A proxma
segment s harvested based on ts mesenterc bood suppy and nset nto the neck
n the soperstatc drecton. Dsadvantages of the |e|una ap ncude hatoss,
sow swaowng transt tmes, and a "wet" voce. Tubed fascocutaneous free ap
optons, ncudng the anteroatera thgh and rada forearm aps, are aso popuar;
however, they may have a greater rsk of strcturng than the free |e|una ap.
Nevertheess, proponents of such aps favor the resutant voca quates and
faster transt tmes.

4ecipient 7essels in te Head and 6eck #or 0ree 0laps
Commony used recpent arteres for free tssue transfer n the head and neck
ncude the psatera superor thyrod, ngua, faca, superca tempora, and
transverse cervca arteres. End-to-sde anastomoss wth the carotd artery s
assocated wth potentay etha carotd bow-out n|ury. Anastomoses wth
contraatera vesses are usefu when psatera vesses are not avaabe, such as
n patents wth recurrent cancer who have undergone prevous free ap
procedures or n patents who have an otherwse dmcut psatera
neck.7,12,17,22 Ven grafts may occasonay be necessary to overcome
nsumcent pedce ength. For venous dranage, trbutares of the superca and
deep |uguar systems are convenent. Fnay, protecton of the ma|or vesses and
nerves of the neck s possbe after neck dssecton by overayng resdua free ap
tssues. Ths aso ads n mprovng the contour and symmetry of the neck for
aesthetc purposes and obterates any dead space.

$o%plications
Apart from the genera compcatons that may be encountered wth any ma|or
operaton or proonged anesthesa, there exst severa specc potenta
compcatons of head and neck abatve and reconstructve surgery. Specc
ntraoperatve compcatons ncude ar embous, pneumothorax, and n|ures to
mportant vesses, ymphatcs, or crana nerves. Specc peroperatve
compcatons ncude carotd artery bow-out, ap necross, nfectons, sava or
chye eakage, arway probems, and acute psychatrc dsturbances. Exampes of
ater compcatons are proonged pan syndromes, stuas, scar contractures, and
probems assocated wth radotherapy such as ap shrnkage (potentay wth
metawork exposure) and osteoradonecross.

0acial 4eani%ation
Faca nerve parayss s a debtatng and emotonay depressng condton that
presents many functona and aesthetc probems. Loss of mmetc musce actvty
eads to poor artcuaton and droong from ora ncompetence, exposure
keratopathy from dysfunctona acrmaton and paraytc ectropon, and mpared
socazaton from faca dsgurement and dmcuty expressng emoton. Faca
nerve dysfuncton has a number of possbe causes, ncudng oncoogc resecton,
tempora bone or sku base surgery, trauma, congenta condtons (Mbus'
syndrome), and dopathc orgn. The man consderatons n treatment are
management of forehead and brow symmetry, eyed cosure, ora competence and
symmetry, and sme dynamcs. The ong-term goas ncude norma statc
appearance, symmetry wth movement, and restoraton of vountary muscuar
contro. Athough the best resuts usuay requre mutstaged, compex surgeres,
the edery patent s better served by a snge-stage procedure that provdes
mmedate mprovement.

6eural TecniAues
Traumatc n|ures to the faca nerve wthout segmenta nerve oss are best treated
wth prmary end-to-end neurorrhaphy of the faca nerve stumps. The success of
ths repar depends on accurate approxmaton of nerve ends and achevement of a
tenson-free epneura repar wth ne sutures, usuay 8-0 nyon or ner. In
segmenta faca nerve oss due to trauma or oncoogc resecton, nterpostona
nerve grafts ead to the most successfu reconstructon and may approach the
resuts of prmary repar. Graftng deay s performed at the tme of the n|ury
rather than n deayed fashon. Donor nerves ncude the cervca pexus, great
aurcuar nerve, and sura nerve. Tmng of reanmaton after nerve repar depends
on dstance of the repar from the motor end pates. Axona regeneraton proceeds
at approxmatey 1 mm/d, whereas motor end pates deterorate at approxmatey
1% per week and are gone by 2 to 3 years. In genera, faca tone returns
approxmatey 6 months after repar and vountary moton a few months ater.43
Probems assocated wth faca nerve repar and graftng are weakness, mass
movement (synknesa), and dysknesa. If the proxma faca nerve stump s
avaabe but the dsta stumps are not, the cervca pexus can be harvested and
proxmay anastomosed to the faca nerve stump and dstay mpanted nto the
mmetc musces to aow neurotzaton and parta restoraton of functon.

Nerve transfer technques borrow other oca crana nerves to nnervate the dsta
faca nerve stump f graftng cannot be done. Ths requres the avaabty of dsta
faca nerve or nerve branch stumps. Typcay used donor nerves ncude the
psatera hypogossa nerve, spna accessory nerve, and cross-face sura nerve
graft from a contraatera faca nerve branch (redundant bucca or zygomatc
branch). Dsadvantages of ths technque ncude those of nerve repar or graftng
pus oss of donor nerve functon and faca hypertona. Transfer of the compete
hypogossa nerve creates psatera tongue parayss and hemtongue atrophy
wth md to moderate ntraora dysfuncton.43

,uscle Transposition TecniAues
A of the aforementoned neura technques rey on the presence of a functona
dsta neuromuscuar unt. When the dsta neuromuscuar unt s decent, as n
congenta faca parayss or n stuatons n whch reconstructon s not undertaken
unt 2 to 3 years after the orgna nsut, musce transposton s consdered.
Musce transposton technques requre ntense muscuar retranng to acheve the
ntended dynamcs. A cassc musce dynamc faca sng uses the temporas
musce, nnervated by the trgemna nerve and perfused by the deep tempora
branch of the nterna maxary artery. The musce s reeased aong wth ts
aponeuross from the tempora fuson ne, reected nferomeday, and attached
to the modous at the ora commssure, the nasoaba fod, and potentay the
orbcuars ocu. Dsadvantages ncude ack of spontaneous movement,
temporomandbuar |ont dysfuncton, and soft tssue funess over the zygomatc
arch. Other transferabe musce unts ncude the masseter musce and the anteror
bey of the dgastrc musce. The atter s usefu n restorng depressor functon of
the ower p n cases of soated parayss of the margna mandbuar branch of the
faca nerve.43

Inner+ated 0ree Tissue Trans#er
Mcrosurgca free nnervated musce transfer may be consdered n the same
stuatons as oca musce transfers but s especay approprate when concomtant
soft tssue augmentaton s needed. Musces descrbed for ths purpose ncude the
gracs, atssmus dors, serratus anteror, and pectoras mnor musces. The
procedure may be performed n a snge stage f the proxma faca nerve stump s
avaabe for anastomoss or f a ong enough donor musce nerve s present to
reach the contraatera faca nerve branches. Often, however, t s a staged
procedure begnnng wth estabshment of a oca neura source va cross-faca
nerve graftng. The extent of axona regeneraton through the graft s montored
usng Tne's test. After sumcent axona progresson, approxmatey 6 to 12
months, the free musce transfer s performed va vascuar anastomoses to the
superca tempora or faca vesses, recpent and donor nerve coaptaton, and
xaton of the musce to the zygoma superoateray and to the nasoaba fod,
upper p orbcuars, and ower p orbcuars nferomeday. Dsadvantages of free
musce transfer ncude donor ste morbdty, engthy surgca tmes, and the need
for specazed mcrosurgca sks.

1ncillary Procedures
One of the most mportant goas of treatment for faca parayss s rehabtaton of
the perocuar regon. Ths ob|ectve may be smpy acheved wth mpantaton of
god or patnum upper eyed weghts, whch aows gravty to assst wth d
cosure. Statc fasca sngs are used to mprove symmetry when comorbd
condtons precude more extensve and staged surgeres. Sng materas ncude
tensor fascae atae, Gore-Tex, and human aceuar derma aograft. Nonsurgca
technques pay a sgncant roe n mprovng faca symmetry, both as a prmary
nterventon and an ad|unct to surgery. Contraatera mmetc musce hypertoncty
s tempered wth botunum toxn n|ectons. Fnay, soft tssue re|uvenatve
technques such as cervcofaca rhytdectomy, bepharopasty, browft, and
mdface ft can mprove the soft tssue ehects of faca nerve parayss (Fg. 45-40).
Fg. 45-40.

Faca reanmaton treatment
agorthm.

Breast 4econstruction
Breast cancer s the most common magnancy and the second eadng cause of
cancer-reated death among women n the Unted States. One n eght women w
deveop breast cancer sometme durng her fe (overa fetme rsk). Breast
reconstructon began as a means to reduce chest wa compcatons and
deformtes from mastectomy. Reconstructon has now been shown to benet
women n terms of psychoogc we-beng and quaty of fe.44 The goa of breast
reconstructon s to re-create form and symmetry whe avodng deay n ad|uvant
cancer treatment. A number of studes have shown that breast reconstructon, both
mmedate and deayed, does not mpede standard oncoogc treatment, does not
deay detecton of recurrent cancer, and does not change the overa mortaty
assocated wth the dsease.3,45-47

Preoperatve counseng of the breast cancer patent regardng reconstructon
optons shoud ncude dscusson of the tmng and type of reconstructon,
aternatves to surgca reconstructon, and reastc expectatons. The pastc
surgeon and surgca oncoogst must mantan cose communcaton to acheve
optma resuts.

Ti%ing o# 4econstruction
Immediate reconstruction s dened as ntaton of the breast reconstructve
process at the tme of the abatve surgery. Ths s usuay done n patents wth
eary-stage dsease for whom there s ow expectaton of postoperatve radaton
therapy. Immedate reconstructon takes advantage of the preserved, suppe skn
enveope made possbe by the skn-sparng mastectomy approach. In genera, ths
aows a more aesthetcay peasng and symmetrc reconstructon. It s aso
psychoogcay advantageous to the patent to avod vng wth the mastectomy
deformty, as the patent must wth deayed reconstructon. Furthermore, the cost
to the medca system s ess wth mmedate reconstructon, because fewer
operatons are requred than for staged procedures. Dsadvantages ncude the
potenta deay of ad|uvant therapy due to surgca ste compcaton, parta
necross of mastectomy skn aps, and the possbty that unantcpated
postoperatve radaton therapy s recommended based on pathoogy nformaton.
Breast reconstructons by a technques are adversey ahected by radaton
therapy, and many surgeons fee reconstructon shoud be deayed unt at east 6
months after treatment.

Deayed breast reconstructon s ntated at east 3 to 6 months after mastectomy.
Ths approach avods mastectomy ap unreabty and radaton therapy
unpredctabty. However, the patent s sub|ected to an addtona operatve
procedure, and overa cosmetc resut s often worse (especay wth autoogous
tssue reconstructon).

Partial Breast 4econstruction
Over the ast decade many women have chosen breast conservaton therapy (BCT)
consstng of segmenta mastectomy wth sentne ymph node bopsy and/or
axary ymph node dssecton combned wth postoperatve whoe-breast
rradaton. Athough ths ess nvasve cancer treatment s qute beneca to many
women, sgncant breast deformty can resut from the tssue remova and
radaton-nduced changes, especay n women wth sma breasts. /ncoplastic
surgery refers to the set of technques deveoped to essen breast deformty from
parta mastectomy, both n the deayed and the mmedate settngs. One of the
most common methods of mnmzng defect vsbty n arge-breasted women s
to rearrange the breast parenchyma at the tme of tumor extrpaton usng
reducton mammopasty technques. Dermatoganduar pedces supportng the
nppe-areoar compex can be desgned n any number of orentatons to avod the
defect ocaton. Ths procedure, combned wth tradtona contraatera breast
reducton, can resut n exceent cosmetc outcomes, often better than
preoperatve appearance (Fg. 45-41). The atera thoracodorsa ap, based on the
atera ntercosta perforators at the nframammary fod, s partcuary usefu n
correctng atera breast defects48 (Fg. 45-42).
Fg. 45-41.

Preoperatve (1) and 1-week postoperatve (B) photos of a 52-year-od patent wth
cancer at the 6 o'cock poston of the eft breast. Oncopastc superomeda pedce
reducton on the eft breast was performed smutaneousy wth a eft segmenta
mastectomy of the eson and a contraatera symmetrzaton reducton.
(Photographs reproduced wth permsson from M. Gmbe.)

Fg. 45-42.

Preoperatve, ntraoperatve, and 4-month postoperatve photos of a 66-year-od
woman wth rght breast cancer at the 10 o'cock poston. Oncopastc atera
thoracodorsa ap reconstructon was performed smutaneousy wth a rght breast
segmenta mastectomy of the eson.
(Photographs reproduced wth permsson from M. Gmbe.)

One drawback of these oncopastc technques when performed at the tme of
segmenta mastectomy s the chance that, f the specmen margns are not cear,
the reconstructon must be taken down to aow for re-excson. The oncoogc
mpcatons of reusng the ap n ths settng are uncear. Another shortcomng s
the potenta for fat necross, especay dstay, n these nonaxa pattern aps.

I%plant-Based 4econstruction
By necessty or patent choce many women undergo mastectomy for oca contro
of breast cancer. In fact, recenty n response to the ncreased recognton of
mutfoca dsease and experence wth poor aesthetc resuts after BCT n sma-
breasted patents, some women have chosen mastectomy despte beng
canddates for BCT. The smpest method of reconstructng the breast s pacement
of an mpant nto the mastectomy defect. Occasonay an mpant may be paced
at the tme of mastectomy as a one-stage mound reconstructon. Usuay, however,
the rst stage nvoves pacement of a scone she tssue expander under the
chest wa muscuature (pectoras ma|or, serratus anteror, superor rectus sheath),
foowed by expanson of the skn and pocket weeky over the foowng 3 months.
The patent then returns to the operatng room for remova of the expander and
pacement of a sane or scone breast mpant (Fgs. 45-43, 45-44). After
exhaustve nvestgaton, scone mpants have been proven as safe and ehectve
as sane mpants n breast augmentaton and reconstructon. After another 3
months, the nppe s reconstructed, usuay under oca anesthesa.
Fg. 45-43.

Tssue expanson and mpant-based breast
reconstructon.
(Iustratons reproduced wth permsson from M.
Gmbe.)

Fg. 45-44.

Batera tssue expander/mpant-based breast reconstructon. Appearance
preoperatvey (1) and 2 months after sane mpant exchange (B).
(Photographs reproduced wth permsson from M. Gmbe.)

The advantages of the tssue expander/mpant-based reconstructon are absence
of donor ste morbdty, short operatve tmes, and short recovery perods. The
dsadvantages ncude the need for more reconstructve stages and onger
cumuatve tme to competon of reconstructon. Impant breast reconstructons
tend to ack the natura breast fee and ptotc appearance. Ths s partcuary
notceabe n unatera reconstructons. Compcatons reated to the tssue
expander or mpant ncude nfecton, maposton, hematoma, seroma, and
rupture and deaton. Long term the most common probem requrng reoperaton
s the formaton of dense scarrng around the mpant (capsuar contracture)
causng rmness, vsbe deformty, and even dscomfort. In addton, mpants are
medca devces that undergo mechanca wear, whch utmatey eads to eakage
and deaton. When a reasons are taken nto account, the chance that a patent
w need addtona surgery on her reconstructed breast wthn 5 years of mpant-
based reconstructon s approxmatey 35%.49 The resuts worsen and the rate of
compcaton ncreases further when mpants are paced n an rradated chest
wa, regardess of whether the radaton therapy occurs before or after
reconstructon. The use of mpants n such cases generay s dscouraged.

Total 1utologous Tissue 4econstruction
An entrey dherent way to reconstruct the breast mound avods the pacement of
mpants n favor of usng ony the patent's own redundant tssue. Indcatons for
tota autoogous breast reconstructon are many and vared, ncudng patent
preference, prevous or antcpated chest wa radaton treatment, a ptotc
contraatera breast, and prevous faed mpant reconstructon. Contrandcatons
are ack of a sutabe donor ste due to scarrng or mnma adposty, morbd
obesty, and serous comorbdtes that precude a onger surgery and recovery
perod.

The most commony used donor ste s the abdomen. Most women n the breast
cancer patent popuaton have redundant skn and fat n the ower abdomen that
may be transferred to the chest wa and fashoned nto a breast mound. Many
technques have been deveoped to transfer ths tssue, both as pedced
myocutaneous aps and as free aps. The workhorse abdomna ap for breast
reconstructon s the pedced transverse rectus abdomns myocutaneous (TRAM)
ap. Ths ap s based on the superor epgastrc vesses that run on the
undersurface of the rectus abdomns musce. A transversey orented skn padde
wth underyng fat s soated based on ts perforatng vesses that course through
the rectus musce to |on the man superor epgastrc pedce. The ap, aong wth
the rectus musce and bood suppy, s tunneed under the anteror chest wa and
devered nto the mastectomy defect, where t s then shaped nto a breast mound.
The donor ste s cosed n a manner smar to an abdomnopasty. The advantages
of ths and a tota autoogous reconstructon technques are creaton of a breast
that ooks and fees natura, that changes voume aong wth the patent's weght
(and the contraatera natura breast), and that avods the potenta compcatons
of breast mpants. In addton, patents are often peased to have the sde benets
of an abdomnopasty. The pedced TRAM ap procedure s aso reatvey quck for
a tota autoogous reconstructon. Downsdes ncude the potenta for parta or
compete ap faure, fat necross, funess n the upper abdomen from the
tunneed pedce, abdomna wa buge or herna, and abdomna wa weakness.

The free TRAM ap was ntroduced to mprove on the sometmes mted voume of
tssue that can be carred by the reatvey ndrect bood suppy of the pedced
TRAM's superor epgastrc vesses. The free TRAM ap s smar to the pedced
TRAM ap but s based on the deep nferor epgastrc vesses, whch are the
domnant bood suppy to the ower abdomen. The ap s harvested as a free ap
and the deep nferor epgastrc artery and ven are anastomosed to recpent
vesses n the chest, usuay the nterna mammary or the thoracodorsa vesses. A
renement to ths method s the musce-sparng free TRAM ap procedure, n whch
ess fasca and rectus abdomns musce s harvested wth the ap to mnmze
donor ste morbdty. The utmate musce-sparng free TRAM ap s the deep
nferor epgastrc perforator ap (Fg. 45-45). In ths case, the fasca s opened but
no musce s ncuded wth the ap, and the perforatng vesses of the deep nferor
epgastrc system are dssected between the musce bers to |on the man pedce.
When patents are carefuy seected, musce-sparng technques decrease
abdomna wa morbdty and ncrease usefu pedce ength for mcrosurgery
wthout sgncanty compromsng ap perfuson50 (Fg. 45-46A and 45-46B).
Fnay, n some patents the ower abdomna tssue may be transferred to the
breast as a free ap wthout voatng the abdomna wa fasca at a. The
superca nferor epgastrc artery s capabe of supportng enough abdomna
tssue voume to reconstruct the breast. Because ths artery and ts accompanyng
ven do not traverse the anteror rectus sheath, the ap can be harvested wth no
more abdomna wa morbdty than an abdomnopasty. Unfortunatey ths artery
s frequenty absent or too dmnutve n sze to ensure a reabe anastomoss.
Despte the many advantages of mcrosurgca tota autoogous breast
reconstructon, t s assocated wth onger operatve tmes than pedced TRAM
procedures, requres expertse n mcrosurgery, and has the potenta for compete
ap faure due to mcrovascuar thromboss.
Fg. 45-45.

Deep nferor epgastrc perforator ap breast
reconstructon.
(Iustratons reproduced wth permsson from M.
Gmbe.)

Fg. 45-46.

12 Le,t upper and lo0er panels2 Free transverse rectus abdomns myocutaneous
(FTRAM) ap and ts donor ste defect. iddle upper and lo0er panels2 Musce-
sparng FTRAM ap and ts donor ste defect. "ight upper and lo0er panels2 Deep
nferor epgastrc perforator ap and ts donor ste defect. B2 Preoperatve and
postoperatve photos of a 43-year-od woman wth a eft musce-sparng FTRAM
breast reconstructon and rght symmetrzaton reducton mammopasty.
(Photographs reproduced wth permsson from M. Gmbe.)

I%plant and 1utologous Tissue 4econstruction
The pedced atssmus dors myocutaneous ap procedure s a straghtforward,
reabe method used for breast reconstructon. It s often reserved for
reconstructng breasts when other methods have prevousy faed. The atssmus
ap s reegated to second-choce status because t carres the ma|or dsadvantage
of autoogous tssue reconstructon (donor ste morbdty) as we as a of the
potenta compcatons assocated wth breast mpants. That asde, the atssmus
ap/mpant-based reconstructon can produce exceent cosmetc resuts wth
reatvey ow donor ste morbdty (Fg. 45-47). The atssmus dors musce wth
overyng skn padde s eevated based on ts thoracodorsa vesse pedce,
tunneed through the axa, and devered nto the mastectomy ste. After parta
nsettng, ether a tssue expander or permanent mpant s paced behnd the
musce to gve adequate voume to the reconstructon (Fg. 45-48). Drawbacks
specc to ths method ncude contour rreguarty of the back, hgh rate of
postoperatve seroma, and notceabe weakness n the shouder (uncommon).
Fg. 45-47.

Preoperatve and postoperatve photos of a 58-year-od woman wth a eft atssmus
dors ap/scone mpant breast reconstructon and rght symmetrzaton
mastopexy.
(Photographs reproduced wth permsson from M. Gmbe.)

Fg. 45-48.

Latssmus dors ap/mpant-based breast
reconstructon.
(Iustratons reproduced wth permsson from M.
Gmbe.)

1ccessory Procedures
After creaton of the breast mound, renements and accessory procedures are
performed after approxmatey 3 months. These may ncude mound revson va
posucton or drect excson, scar revsons, fat graftng, and nppe-areoa compex
reconstructon. Scores of methods have been descrbed for reconstructng the
nppe. These ncude oca ap technques (e.g., star ap, skate ap, C-V ap),
graftng technques (contraatera nppe/areoa sharng, gron skn, aba skn), and
tattoong. Nppe reconstructons are ntay purposefuy overpro|ected n
antcpaton of approxmatey 50% oss of pro|ecton over the rst 6 months.

4adiation-4elated $onsiderations
Wth some notabe exceptons, most surgeons advocate avodance of mpant-
based breast reconstructon n chest was that have prevousy receved radaton
or are key to receve radaton due to the reatvey hgh rate of compcatons and
dsappontng resuts. Deayed tota autoogous reconstructons brng heathy
nonrradated tssue to repace the damaged brotc tssue and are the preferred
mode of breast reconstructon n ths settng. Smary, atssmus dors/mpant
reconstructons repace much of the rradated skn, whch probaby expans to
some degree why, n the face of prevous rradaton, mpants far better wth an
overyng atssmus ap than wthout.

The queston of whether tota autoogous reconstructons shoud be done before or
after antcpated radaton therapy s st controversa. Those n favor of deayng
the reconstructon argue that an rradated ap w exhbt shrnkage and bross
that subtracts from the overa aesthetc resut. Those n favor of performng
mmedate reconstructon n ths settng fee that, because mmedate
reconstructons have nherenty better aesthetcs, the mperfect resut due to
rradaton t s st comparabe to the resut of deayed reconstructon wthout the
addtona operaton. To date no prospectve study has been performed comparng
the two approaches.

Trunk and 1bdo%inal 4econstruction
In the trunk, as n most areas of the body, choce of reconstructve method s
determned by the ocaton and sze of the defect, and the propertes of the
decent tssue. A dstncton s made between parta-thckness and fu-thckness
defects n decdng between grafts, aps, synthetc materas, or a combnaton of
technques. Unke the head and the ower eg, the trunk harbors a reatve weath
of regona transposabe axa pattern aps that aow sturdy reconstructon, ony
rarey requrng dstant free tssue transfer. Indeed, the trunk serves as the body's
arsena, provdng ts most robust aps to rebud ts argest defects.

Toracic )all
The chest wa s a rgd framework desgned to resst both the negatve pressure
assocated wth respraton and the postve pressure from coughng and from
transmtted ntra-abdomna forces. Furthermore, t protects the heart, ungs, and
great vesses from externa trauma. Reconstructons of chest wa defects must
emuate these functons.

The pectoras ma|or musce s the workhorse pedced ap for coverage of the
sternum, upper chest, and neck. It s a type of V ap wth one domnant pedce
(pectora branch of the thoracoacroma artery) and severa secondary segmenta
pedces (ntercosta perforators and the pectora branch of the atera thoracc
artery).51 The musce may be advanced or transposed on ts domnant pedce or
used as a turnover ap based on ts nterna mammary perforators. Both methods
are usefu n coverng the sternum after dehscence or nfecton. Before the
turnover ap s eevated prevous operatve notes shoud be revewed carefuy to
determne whether the nterna mammary artery s st a vabe perfuson source;
the artery, especay the eft, s frequenty used for heart revascuarzaton. The
musce may aso be used for obteraton of ntrathoracc dead space nfectons and
as a myocutaneous ap for head and neck reconstructon. Athough t s a reabe
ap, the oss of the pectoras ma|or musce resuts n upper extremty weakness
and cosmetc deformty from oss of the anteror axary fod.52

The rectus abdomns musce s a type III axa pattern ap that can be based on
the superor epgastrc vesses or the deep nferor epgastrc vesses.51 When
eevated as a myocutaneous ap t can be desgned wth a transverse (TRAM) or
vertca skn padde. Athough the vertca rectus abdomns musce ap has better
vascuarzed skn due to ts mutpe ongtudnay orented perforators, the TRAM
ap provdes a arger area of donor skn that can be prmary cosed wth an easy
conceaabe scar. The rectus abdomns musce s frequenty used for ower
sternum reconstructon when the pectoras musce s nsumcent. It can aso be
used n pedce or free ap conguraton for repar of arge chest wa defects from
cancer resecton (Fg. 45-49).
Fg. 45-49.

Top ro0: Free transverse rectus abdomns musce reconstructon of a arge parta-
thckness chest wa defect. !ottom ro02 Fu-thckness chest wa defect
reconstructed n two ayers wth human aceuar derma aograft and overyng
pedced vertca rectus abdomns musce ap.
(Photographs reproduced wth permsson from M. Gmbe.)

The atssmus dors myocutaneous ap s probaby the most wdey used ap n
nonsterna chest wa reconstructons due to ts broad sze, ocaton, reabty, and
pedce ength. The ap s based on the thoracodorsa vesses arsng from the
subscapuar system. Its secondary bood suppy comes from the posteror
ntercosta and umbar vesses.51 The arc of rotaton of ths ap can extend to
most areas on the psatera torso as we as to the abdomen, head and neck, and
upper arm. The serratus anteror musce can be ncuded on the same vascuar
pedce to further ncrease ts surface area. Use of ths donor ste s reatvey we
toerated, but shouder weakness can be sgncant. The ma|or drawbacks of the
atssmus ap are ts conspcuous scar and the hgh rsk of seroma.52

The trapezus musce ap, based on the transverse cervca vesses, s generay
used as a pedced ap to cover the upper mdback, base of neck, and shouder.
The superor porton of the musce aong wth the acroma attachment and spna
accessory nerve are preserved to mantan shouder eevaton functon. Other
usefu aps of the thoracc regon ncude the scapuar/parascapuar
fascocutaneous ap, the externa obque ap, the meday or ateray based
thoracoepgastrc skn aps, and the omenta ap.

When a fu-thckness defect of the chest wa nvoves more than two ad|acent rbs,
the nherent rgdty of soft tssue aps may provde nsumcent chest wa ntegrty.
Athough cadaverc bone and autoogous bone grafts have been used n the past to
end structura support, the avaabty of we-toerated synthetc and boogc
materas has become more common. These materas ncude poypropyene
(Proene), poyethyene (Marex), and poytetrauoroethyene (Gore-Tex) meshes,
methy methacryate, and aceuar derma aograft. Even f these avascuar foregn
bodes must be removed due to chronc nfecton, often a thck brous ayer of
tssue w have formed that can mantan chest wa stabty.52

1bdo%inal )all
The abdomna wa aso protects the nterna vta organs from trauma, but wth
ayers of strong torso-supportng musces and fasca rather than wth osseous
structures. The goas of reconstructon are restoraton of structura ntegrty,
preventon of vscera eventraton, and provson of dynamc muscuar support.
Defects n the abdomna wa may arse from trauma, oncoogc resecton,
congenta deformtes, and nfecton. By far the most common reason for
abdomna wa decency, however, s ncsona fasca dehscence and hernaton
after aparotomy. When a reconstructon pan s beng formuated, carefu physca
examnaton and revew of the medca hstory w hep prevent seecton of an
otherwse sound strategy that, because of prevous ncsons and trauma, s
destned for faure.

Partial /e#ects o# te 1bdo%inal )all
Large defects of the abdomna skn and subcutaneous tssue are usuay easy
controed wth skn grafts, oca advancement aps, or tssue expanson.
Myofasca defects are more dmcut to manage. The abdomna wa fasca requres
a mnma-tenson cosure to avod dehscence, recurrent ncsona herna
formaton, or abdomna compartment syndrome.53 Prosthetc meshes are
frequenty used to repace the fasca n cean wounds and n operatons that create
myofasca defects. When the area of fasca decency s contamnated, as n
nfected mesh reconstructons, enterocutaneous stuas, or vscous perforatons,
prosthetc mesh s avoded because of the rsk of nfecton. A deayed
reconstructon can be performed by nsettng a resorbabe poygactn (Vcry) mesh
that w eventuay granuate to aow skn graftng. The ensung herna s repared
ater wth prosthetcs under ceaner condtons. The separaton-of-components
procedure has en|oyed much success n cosng arge mdne defects wthout
resortng to mesh. Ths procedure nvoves advancement of batera myofasca
aps consstng of the anteror rectus fasca/rectus abdomns/nterna
obque/transversus abdomns musce compex. Mobty of ths myofasca unt s
created by reease of the externa obque musce at the semunate ne. Mdne
defects measurng up to 10 cm superory, 18 cm centray, and 8 cm nferory can
be cosed usng separaton of components.54 Ths technque s ess ehectve n
cosng atera defects, for whch regona musce and fasca aps are usuay
better suted (rectus abdomns ap, nterna obque ap, externa obque ap).53

Fu-thckness abdomna defects and arge myofasca defects requre arge robust
pedced aps or free aps for cosure. The tensor fascae atae pedced ap, based
on the ascendng branch of the atera crcumex femora vesses, s usefu n
reconstructng the ower two thrds of the abdomen. Batera aps can be used for
very arge defects, athough the skn-grafted donor ste s unsghty. The rectus
femors ap and the vastus ateras ap can be used for smaer ower abdomna
defects. The "mutton-chop" ap, whch s an extended rectus femors ap wth
fasca ata ncuded dstay, has been used successfuy n cosng massve
defects.55,56 Large defects of the upper abdomna wa may be repared wth
pedced extended atssmus dors aps wth attached pregutea fasca. Very arge
fu-thckness defects, especay superory, are best treated wth free tssue
transfer of arge myofasca unts such as the atssmus dors or the tensor fascae
atae. These can aso be nnervated aps to re-estabsh contracte force and
strength n the abdomna wa.

38tre%ity 4econstruction
Posttrau%atic 4econstruction
Hstorcay, sgncant advances n the treatment of traumatc wounds have
occurred durng those tmes of greatest need-wars. Word War I was cosey
predated by the begnnngs of aseptc surgery and anesthesa, and marked a
turnng pont n wound management and trauma surgery. Wth the begnnngs of
modern orthopedc and pastc surgery; mprovements n the understandng of
anesthesa, trauma resusctaton, and nfecton; and the avaabty of eary
antbotcs, these tmes wtnessed a move away from amputaton for a compound
extremty fractures toward an ncrease n attempts at mb savage. The
ntroducton and maturaton of mcrosurgca technques brought ncreasngy
successfu dsta extremty repantatons and free ap reconstructons. Soft tssue
reconstructon thus advanced aongsde evovng technques of bone xaton, |ont
reconstructon, and genera vascuar surgery. Current ower extremty
reconstructon ncorporates the use of vascuarzed bone, composte tssues, and
functonng musce transfers taored to the gven defect.57 The future may behod
the use of tssue-engneered vascuarzed composte tssue constructs and
cadaverc composte tssue aotranspantaton.

Common causes of hgh-energy ower extremty trauma, outsde of wartme,
ncude road tramc accdents, fas from a heght, drect bows, sports n|ures, and
gunshots. Understandng the anatomy of the ower mb compartments, nerve and
vascuar suppes, musce functons, skeeta structure, and mechancs s essenta
for accurate bony and soft tssue restoraton for functon and appearance. Severa
mb-savage scorng systems have been suggested to ad n the decson regardng
whether to amputate or attempt mb savage, but ther routne use remans
controversa; nevertheess, they can provde gudance durng ths fe-aterng
decson process.58 Open (compound) fractures are often cassed accordng to
the system devsed by Gusto and coeagues (Tabe 45-12).59

Table 45-1* Gustilo and 1nderson $lassi.cation o# $o%pound 0ractures

$lassi.c
ation
/escription
Grade I Wound <1 cm; mnma contamnaton, commnuton, and soft tssue
damage
Grade II Wound >1 cm; moderate soft tssue damage and mnma perostea
strppng
Grade IIIa Substanta contamnaton and severe soft tssue damage but adequate
fracture coverage; usuay due to hgh-energy trauma
Grade IIIb Substanta contamnaton, perostea strppng, severe soft tssue
damage, and nadequate fracture coverage; usuay due to hgh-energy
trauma
Grade IIIc Any open fracture wth an assocated artera n|ury requrng repar

In addton to foowng standard mutpe trauma evauaton and resusctaton
gudenes, the mutdscpnary team must assess the perphera neurovascuar
status, soft tssue defects, and conguraton of fractures.57,60 Bony stabzaton
may be crtca to controng fracture hemorrhage. Angography or Dopper
utrasound examnaton may hep assess vascuar ntegrty. Compartment
syndrome must be montored for, and fascotomes performed when necessary.
Anttetanus vaccne and antbotcs shoud be provded as soon as possbe
accordng to contemporary gudenes.61 An evauaton of the patent as a whoe
aows treatment to be panned wthn the context of comorbdtes, socoeconomc
consderatons, and rehabtatve potenta. The oss of pantar sensaton may favor
beow-knee amputaton. Revascuarzaton of a manged ma|or extremty brngs a
rsk of massve reperfuson n|ury and mutpe organ faure.

In terms of surgca management, the order of repar s fracture stabzaton
foowed by vascuar repar and reconstructon of a stabe soft tssue enveope. The
choce of method for soft tssue coverage s determned by the ocaton and extent
of the n|ury (Tabe 45-13). Coverage for weghtbearng areas shoud be durabe,
stabe (nonshearng), and sensate. Propery tted footwear provdes essenta
protecton aganst pressure-reated compcatons. Spt-thckness skn grafts are
reasonabe for coverage of exposed heathy musce or soft tssue. Loca aps may
be used to cover smaer defects. Free tssue transpantaton s preferred for arger
or more compex defects wth bony exposure, partcuary n the mdde and ower
thrds of the eg where mted oca soft tssues are avaabe for reconstructon.
Free aps need not be mted to provdng ony soft tssue coverage; ncorporaton
of vascuarzed bone, such as of bua or ac crest, can ad n fracture
management. Chmerc ap conguratons can mprove ap nsettng nto
composte defects. Fow-through desgns, such as the anteroatera thgh ow-
through free ap, can be used to brdge segmenta vascuar defects to
revascuarze the dsta extremty. Muscuar aps can be motor nnervated to
restore ost musce functons at the recpent ste (Fg. 45-50).62-64 Other
technques, such as tssue expanson and vacuum-asssted cosure, may be
ndcated n seect crcumstances. Tradtona cross-eg aps are amost never used
nowadays; they cause compete mmobzaton and ncrease the rsk of deep ven
thromboss and contracture formaton.

Table 45-1- So%e Lo!er 38tre%ity 4econstructi+e ?ptions #or So#t Tissue
$o+erage a#ter 0racture

1rea o# /e#ect 4econstructi+e ?ptions
Femur Sartorus musce/MC ap (anteror defects)
TFL musce/MC ap (posteror defects)
Vastus ateras/medas musce/MC (md to ower thgh
defects)
ALT for fascocutaneous ap
Free osseous aps usefu for segmenta femur defects
Knee and proxma thrd of
tba
Gastrocnemus musce (meda or atera head, or both)
wth SSG
Dstay based ALT ap
Free tssue transfer for arger defects
Mdde thrd of tba Soeus musce wth SSG
Gastrocnemus head(s) wth SSG
Fexor dgtorum ongus musce
Tbas anteror musce "book ap" (preserves functon)
Free tssue transfer for arger defects
Dsta thrd of tba Free tssue transfer usuay the rst choce
Reversed sura artery ap
Peronea perforator fascocutaneous ap
Loca musce aps for smaer defects
ALT = anteroatera thgh; MC = myocutaneous; SSG = spt-thckness skn graft; TFL
= tensor fascae atae.
Fg. 45-50.

Soft tssue and bony reconstructon of a Gusto IIIb open segmenta fracture of the
rght femur usng a doube-barreed bua osteoseptocutaneous free ap. 12
Antbotc-mpregnated beads were paced as a temporary spacer n the segmenta
femur bone gap after prmary dbrdement; an externa xator s n pace. B2 Two
weeks ater, a free eft bua osteoseptocutaneous ap was harvested, osteotomzed
nto a doube-barreed conguraton, and transferred as a mcrovascuar free ap to
the contraatera mb. $2 The skn padde of the free ap provdes a usefu means for
postoperatve cnca montorng of the vabty of the underyng bua bone. / and
32 The patent s shown fuy weghtbearng wthout assstance 20 months after
reconstructon; hypertrophy of the doube-barreed bua was noted on the
radographs.

Wth the avaabty of mcrovascuar free tssue transpantaton, radca
dbrdements can be adequate even for the argest wounds. Eary one-stage
wound coverage and bony reconstructon s generay advocated whenever
possbe.2,57,60,61 It s reasonabe for reconstructon to be deferred brey,
however, f there reman tssues of questonabe vabty, so that these can be
reassessed and dbrded as requred. Temporary pacement of a boogc dressng
s one method to assess the vabty and ceanness of questonabe tssues; a skn
graft w fa f ad onto an unheathy graft bed. If dbrdement produces an
rreguar dead space that cannot be competey obterated, or f dbrdement
remans questonabe even after a second ook, the resutant cavty may be ed
wth antbotc-mpregnated beads or avaabe vascuarzed soft tssues to act as a
spacer unt dentve reconstructon s possbe. Ths appes aso to segmenta
bone osses wthn a soft tssue enveope of doubtfu vabty. In these stuatons,
soft tssue coverage preferaby s st acheved eary; bony reconstructon can be
competed at a ater date, when both the bone and soft tssue enveope are stabe
and heathy. Athough t remans debated whether fascocutaneous or muscuar
(muscuocutaneous or musce aone) aps are superor for treatng compound
fractures, t s crtca to obterate dead space wth fresh tssue, and ths s often
more easy acheved usng musce.

Osteomyets often compcates nadequatey dbrded compound eg fractures.
Deayed coverage aso appears to ncrease the rsk of ths dreaded compcaton.
Generous rrgaton, dbrdement, remova of dead bone (even n a segment),
expedent antbotc therapy, and heathy soft tssue coverage are mportant n
both acute compound fracture and estabshed posttraumatc osteomyets. Large
segmenta bone osses can be addressed wth mcrovascuar free transpantaton of
osseous aps or dstracton engthenng.57,60

When mb savage ether s not possbe or s not n the best nterests of the
patent, attenton s drected to provdng soft tssue stump coverage sutabe for
weghtbearng and aowng ambuaton wth a propery tted prosthess. Ideay,
oca tssues are used; however, when they are unavaabe or nadequate, the
amputated part can be a usefu source of skn grafts or tssues for mcrovascuar
free transfers to the stump, whch preserves ength and avods a more proxma
amputaton.

4econstruction a#ter ?ncologic 4esection
The renements n surgca abaton technques, n ad|uvant radaton therapy and
chemotherapy, and n mb reconstructon methods have opened the possbty for
curatve mb-sparng treatments nstead of amputaton. Extensve soft tssue and
segmenta ong bone defects from radca tumor resecton and radaton-
compromsed wound heang can often be reconstructed nowadays by bera
mportaton of fresh tssues through mcrovascuar free tssue transpantaton
taored to the defect.

/iabetic =lceration
The pathophysoogy of prmary dabetc ower mb compcatons has three man
components: perphera neuropathy (motor, sensory, and autonomc), perphera
vascuar dsease, and mmunodecency. Atered foot bomechancs and gat
caused by paness coapse of gamentous support, foot |onts, and foot arches
change weghtbearng patterns. Bunted pan aows cutaneous ssurng and
uceraton to progress. Mutora nfectons are estabshed amd oca
mmunodecency and mcrovascuopathy. Frank neuroarthropathc Charcot's foot
deformtes may utmatey resut. Cutaneous uceratons may chroncay
deterorate reatvey panessy, nvovng deeper tssues, ncudng bone.
Persstent soft tssue nfecton and osteomyets, worsened by perphera vascuar
compromse and mmunodecency, tradtonay ends n gangrene and
amputaton. Prevousy, 50 to 70% of ower extremty amputatons performed for
nontraumatc causes were due to dabetes.13,31 Improved patent educaton and
medca management, tmeer detecton of dabetc foot probems and referra for
treatment, and the use of more rened technques for wound management have
heped ncrease the chances of mb preservaton.

Dabetc patents wth ower mb dsease often have sgncant mutsystemc
comorbdtes that must be optmzed for surgery; strct peroperatve contro of
bood gucose eves s mandatory. Cnca examnaton must ncude
documentaton of sensory dects, vascuar nsumcences, and evdence of
osteomyets. Pan radographs, MRI, nucear bone scans, and angography or
dupex magng may be ndcated. A patent wth sgncant vascuar dsease may
be a canddate for ower extremty bypass. Nerve conducton studes may dagnose
surgcay reversbe neuropathes at compressve stes and ad n decsons about
whether to perform sensory nerve transfers to restore pantar sensbty. Antbotc
and funga therapes shoud be guded by tssue cuture resuts.

Pastc surgca management starts wth thorough dbrdement of devtazed or
nfected tssues, puruent cavtes, and osteomyetc bone. Methods of wound
cosure are dctated by the extent and ocaton of the postdbrdement defect
(Tabe 45-14). Vacuum-asssted cosure may be approprate for superca defects.
Skn grafts shoud be used cautousy and not n weghtbearng areas. Loca and
regona aps can be used after carefu evauaton of ther vascuarty gven
concurrent perphera vascuar dsease and possbe recent dsta vascuar bypass
procedures. Mcrovascuar free tssue transfers are approprate when defects are
arge or when oca aps are not avaabe. Combnaton ower extremty bypass
and free ap coverage has proved beneca for the treatment of the dabetc foot
n terms of heang and reducton of dsease progresson. Orthopedc surgeons
shoud be consuted to mprove foot bomechancs and address bony promnences
to reduce the rsk of recurrent uceraton. Proper footwear (ncudng orthotc
devces and oh-oadng shoe nserts), hygene, and toena and skn care are
essenta.65

Table 45-14 So%e 4econstructi+e ?ptions #or te /iabetic 0oot

1rea o#
/e#ect
4econstructi+e ?ptions
Forefoot V-Y advancement
Toe sand ap
Snge toe amputaton
Lsfranc's amputaton
Mdfoot V-Y advancement
Toe sand ap
Meda pantar artery ap
Free tssue transfer
Transmetatarsa amputaton
Hndfoot Latera cacanea artery ap
Reversed sura artery ap
Meda pantar artery ap exor dgtorum brevs
Abductor haucs musce ap
Abductor dgt mnm musce ap
Free tssue transfer
Syme's amputaton
Foot dorsum Supramaeoar ap
Reversed sura artery ap
Thnner free aps (e.g., temporopareta fasca, rada forearm,
gron aps)

Ly%pede%a
The ymphatc system provdes a hgh-voume transport mechansm, cearng
protens and pds from the nterstta space to the systemc vascuature by means
of dherenta pressure gradents. Factors that contrbute to crcuatory ymphatc
ow ncude segmenta ymphangon contractty, skeeta musce actvty, and
one-way vaves that prevent backow.66,67 The ymphatcs course throughout the
body aongsde the venous system, nto whch they eventuay dran va the ma|or
thoracc and cervca ducts. Wth ymphatc obstructon, abnorma connectons form
between the superca and deep ymphatcs and between the ymphatc and
venous systems. Lymphatc stagnaton, hypertenson, and vavuar ncompetence
contrbute to edema, nammatory brovascuar proferaton, and coagen
deposton, causng rm, nonpttng sweng wth peau d'orange cutaneous
changes. Lymphoscntgraphy reveas the ymphatc anatomy and quantes
ymphatc ow. MRI provdes anatomc nformaton regardng ymphatc trunks,
nodes, and obstructve esons. It s essenta to rue out neopastc ymphatc
nvason, especay after oncoogc abaton, as a cause of secondary ymphedema.
Lymphangosarcoma s a rare cause of ymphedema that s deady f dagnosed
ate.68

Prmary ymphatc obstructon may arse from congenta maformatons of the
ymphatc system such as ymphatc hypopasa, functona nsumcency, or
absence of ymphatc vaves. Idented genetc causes ncude the autosoma
domnant Mroy dsease. Lymphedema praecox accounts for >90% of cases of
prmary ymphedema, generay appears durng puberty but sometmes as ate as
the thrd decade, and occurs more commony n femaes. It s usuay unatera and
mted to the foot and caf. Lymphedema tarda appears after the age of 35 years
and s reatvey rare. Secondary (acqured) ymphedema s much more common,
wth arass beng the eadng cause wordwde. In Western countres, secondary
ymphedema s more commony the resut of neopasms and ther surgca
treatments and radotherapy.13,67

The manstay of treatment for ower extremty ymphedema s nonsurgca
measures, ncudng one or more of the foowng: use of externa compressve
garments and devces, mb eevaton, admnstraton of antbotcs for epsodes of
ceuts, and specazed compex physca therapy.69 The emcacy of avaabe
surgca optons s generay poor, and these are reserved for cases n whch
aggressve nonsurgca measures have faed. The cassc Chares procedure
nvoved radca excson of ymphedematous fasca and suprafasca tssues wth
skn graftng for coverage; cosmetc outcomes were often dsastrous, and
functona probems arose due to hgh rates of contracture, wound breakdown, and
uceratons. Ths method was ater moded nto mutpe staged excsons of
subcutaneous tssues. Other technques ncude posucton and brdgng
procedures. Mcrosurgca ymphatc-ymphatc, ymphatc-venous, ymphatc-
venous-ymphatc, and ymph node-venous anastomoses have a been tred to
reeve obstructve ymphedema, and a technques show some emcacy eary on;
however, onger-term resuts are hghy varabe.70 Nonsurgca technques can be,
and usuay are, combned wth any of the surgca methods.

Pressure Sore Treat%ent
A pressure ulcer s dened as tssue n|ury, usuay over a bony promnence, due to
pressure or a combnaton of pressure and shear forces. These wounds occur n
patents debtated by age, ness, mmobzaton from orthopedc n|ures, or
spna cord n|ury. Preventon of pressure ucers rst requres dentcaton of
susceptbe patents. Once such patents are dented, measures to prevent
deveopment of uceraton ncude frequent poston changes (by both the patent
and caretakers), use of pressure reducton equpment (ow ar oss mattresses and
seat cushons, hee protectors), nutrtona optmzaton, hygenc contro of
ncontnence, and medca and/or surgca treatment of musce spasm and |ont
contracture. Once an ucer has deveoped these same factors must be carefuy
evauated and decences corrected before embarkng on a compex
reconstructve treatment pan. Successfu reconstructon aso requres a medcay
stabe, cooperatve, motvated patent wth adequate soca support.

Pressure ucers are descrbed by ther stage, based on depth of tssue n|ury (Tabe
45-15).71 Stage I and II ucers are treated conservatvey wth dressng changes
and basc pressure ucer preventon strateges as aready dscussed. Patents wth
stage III or IV ucers shoud be evauated for surgery. The wound s examned for
soft tssue nfecton or abscess, osteomyets, and nvovement of deeper
structures or spaces (e.g., |ont space, urethra, spna cana) to determne the
urgency and specc requrements of the probem. Bood aboratory work and
magng studes are performed to hep estabsh whether soft tssue or bone
nfecton s present. Radographs are usuay adequate to rue out osteomyets; CT
and MRI are hepfu when pan ms are equvoca. Wet gangrenous tssue and
abscesses shoud be surgcay dbrded wthout deay to prevent or treat sepss. In
patents who do not meet the strct reconstructon crtera, dbrdement to heathy
tssue wthout subsequent reconstructon may be the optma treatment. If bone s
present at the wound base, t shoud be dbrded ony to beedng bone and eft
wth a smooth contour. Compete schectomy shoud not be performed for scha
decubtus ucers, because remova of one schum ony transfers subsequent
pressure trauma to the contraatera schum or the perneum. If osteomyets s
present, whch s best proven by cuture of specmens obtaned by ntraoperatve
bone bopsy, ong-term antbotc therapy guded by mcroorgansm senstvty s
ndcated. A speca note shoud be made regardng surgca treatment of spna
cord n|ury patents wth T5 or hgher n|ures. In these patents, manpuaton of a
pressure ucer and even smpe urnary retenton can trgger autonomc
hyperreexa. Ths dangerous condton s characterzed by crtcay hgh bood
pressure eevaton and sympathetc dscharge. Ehectve management s mmedate
recognton and reversa of trgger factors aong wth prompt admnstraton of
pharmacoogc agents to prevent compcatons such as ntracrana and retna
hemorrhage, sezure, cardac rreguartes, and death.

Table 45-15 6ational Pressure =lcer 1d+isory Panel Staging Syste%

$lassi.cati
on
/escription
Stage I Intact skn wth nonbanchabe redness
Stage II Parta-thckness oss of derms; may present as bster
Stage III Fu-thckness oss of derms wth vsbe subcutaneous fat (no deeper
structures exposed)
Stage IV Fu-thckness oss of derms wth exposed bone, tendon, or musce
Unstageab
e
Fu-thckness oss of derms wth ucer base obscured by eschar

Drect cosure of a pressure ucer s rarey performed because t usuay creates
tenson n the heang tssues aready stressed by nonphysoogc externa pressure,
predsposng the cosure to breakdown. Skn graftng s usefu for shaow ucers
wth we-vascuarzed beds that are not sub|ected to hgh mechanca shear.
Unfortunatey, these requrements remove most pressure ucers from skn graft
canddacy. The manstay of deep pressure ucer reconstructon s coverage wth
we-vascuarzed oca aps. There s debate over whether myocutaneous aps are
better than fascocutaneous aps for resurfacng regons prone to excess pressure
and shear. Athough myocutaneous aps have exceent buk and bood suppy,
musce has ow toerance for schemc n|ury. From an anatomc vewpont there s
no pressure pont on the human body where bone s padded by musce. On the
other hand, athough fascocutaneous aps provde reasonabe buk and are
teeoogcay approprate, some argue that subcutaneous fat and fasca have ow
resstance to pressure and shear forces, and have ess robust perfuson than
musce.72

The anatomc ocaton of the pressure ucer naturay has a profound mpact on ap
choce. Regardess of the wound ste, however, the ap desgn shoud be very
arge, more than needed for cosure, so that f the ucer recurs the ap can be
readvanced. In addton, care shoud be taken to pace suture nes, the weakest
part of the reconstructon, away from pressure ponts. Over the ast few decades,
patterns have deveoped n the seecton of partcuar aps for partcuar pressure
sores. Sacra decubt are we treated wth guteus maxmus myocutaneous aps
(Fg. 45-51). In ambuatory patents, ether the superor or the nferor guteus
musce s spared to preserve hp extenson functon. The downsde of usng the
gutea musce s the reatvey boody dssecton. A common aternatve s the
gutea fascocutaneous advancement or rotatona ap. Ischa pressure sores are
generay due to sttng n a wheechar wth mproper cushonng or nsumcent
poston changes. A good rst-choce ap for scha wound reconstructon s the
hamstrng V-Y myocutaneous ap. The guteus maxmus ap may aso be
transposed nferory to cover ths wound. A fascocutaneous aternatve s the
posteror thgh ap, based on the contnuaton of the nferor gutea artery.
Trochanterc ucers deveop from proonged postonng n the atera decubtus
poston or from poory ttng seat or wheechar equpment. The tensor fascae
atae myocutaneous ap s an expendabe musce unt n ambuatory patents that
has a reabe bood suppy. It can be advanced superory or transposed on ts ong
arc of rotaton (see Fg. 45-51). Good second-choce aps are the rectus femors
musce ap and the vastus ateras myocutaneous ap. When pressure sores are
negected they can become conuent, formng arge areas of deep tssue
destructon. Ths dre stuaton may requre hp dsartcuaton and use of the upper
eg soft tssue as a tota thgh ap for coverage.
Fg. 45-51.

Fap reconstructon of pressure ucers. Top ro02 Preoperatve and 1-month
postoperatve photos of a stage IV sacra decubtus ucer treated wth a
myocutaneous guteus maxmus ap. !ottom ro02 Preoperatve and 1-month
postoperatve photos of a stage IV trochanterc ucer treated wth a myocutaneous V-
Y tensor fascae atae ap.
(Photographs reproduced wth permsson from M. Gmbe.)

The postoperatve care after ap reconstructon of pressure ucers s as mportant
for success as the surgery tsef. The authors recommend transfer of the patent
from the operatng room tabe onto an ar-udzed bed, where the patent w
reman for the next 7 to 10 days n the hospta. Metcuous nstructons must be
gven to the nursng stah and therapsts regardng the postonng and rong of the
patent to prevent stressng the suture nes durng these maneuvers. Nutrton and
musce spasm contro are carefuy mantaned. The posthosptazaton care pan,
whch shoud have been arranged preoperatvey, s conrmed to avod apses n
proper care. Patents wth scha sores are advsed to abstan from sttng for 6
weeks to aow for sumcent heang. Care of the pressure ucer patent s a abor-
ntensve process that requres attenton to deta by the surgeon, nurses,
therapsts, caseworkers, and famy. Unfortunatey, sma gaps n care nevtaby
ead to arge gaps n the debtated patent's ntegument.

4econstructi+e Transplant Surgery
Composte tssue aotranspantaton (CTA), such as hand and face transpantaton,
has become a cnca reaty and ohers enormous potenta for many reconstructve
probems, ncudng amputaton of extremtes. However, as wth sod organ
transpantaton, there remans the ssue of aograft re|ecton. In contrast to
vscera organ transpantaton, whch nvoves homogeneous tssues, CTA may
nvove a combnaton of skn, subcutaneous tssue, nerve, bood vesses, musce,
tendon, and bone, and thus carry the antgenctes of a these tssue types. The
basc prncpes of mmunosuppresson for sod organ transpantaton have been
apped to CTA and ncude therapy wth a varety of combnatons of T-ce-
depetng agents, monocona antbodes, cacneurn nhbtors, antmetabotes,
and rapamycn. The compcatons assocated wth mmunosuppresson are we
known, ncudng opportunstc nfectons, metaboc dsturbances, and
magnances. Patents seected to undergo CTA, speccay hand transpantaton,
are young and heathy and therefore more resstant to mmunosuppressve sde
ehects than typcay ess robust sod organ recpents.

As wth any surgca procedure the benets, success rate, and compcatons must
be understood. Unke sod organ transpantaton, CTA s not a fesavng
procedure. There remans much debate over the rsks assocated wth feong
admnstraton of potentay dangerous mmunosuppressve agents to patents who
have no fe-threatenng ness. The utmate goa n CTA research s mmune
toerance n whch the recpent of the aograft remans fuy mmunocompetent
yet does not mount an mmunoogc response to the transpanted aograft.
Accompshment of ths goa woud aow the decrease or possbe emnaton of
mmunosuppressve medcatons. If mmune toerance s acheved, CTA cnca
appcatons w broaden dramatcay as they become the next fronter n
reconstructve surgery73 (Fg. 45-52).
Fg. 45-52.

Hemfaca composte tssue aotranspantaton n a
rat mode.
(Photographs reproduced wth permsson from K.
McLean.)

1estetic Surgery
The Amercan Medca Assocaton denes cosmetic surgery as "surgery performed
to reshape norma structures of the body to mprove the patent's appearance and
sef-esteem." "econstructi+e surgery s performed on structures of the body that
are abnorma due to congenta defects, deveopmenta abnormates, trauma,
nfecton, tumors, or dsease. It s generay performed to mprove functon but may
aso be done to approxmate a norma appearance.74 In practca terms, there are
both reconstructve and cosmetc eements to amost every pastc surgery case,
and the denton of "norma" structure s sometmes uncear. Nevertheess, there
are patents for whom t s a prorty to make surgca changes to ther bodes n the
cear absence of a functona deformty. Aesthetc surgery patents present a
unque chaenge to the pastc surgeon, because the most mportant outcome
parameter s not truy appearance, but patent satsfacton. Optmay, a good
cosmetc outcome w be assocated wth a hgh eve of patent satsfacton. For
ths to be the case, the pastc surgeon must do a carefu anayss of the patent's
motvatons for wantng surgery, aong wth the patent's goas and expectatons.
The surgeon must make a reasonabe assessment that the mprovements that can
be acheved through surgery w meet the patent's expectatons. The surgeon
must appropratey counse the patent about the magntude of the recovery
process, the exact ocaton of scars, and potenta compcatons. If compcatons
do occur, the surgeon must manage these n a manner that preserves a postve
doctor-patent reatonshp.

1ssess%ent o# 0acial 1estetics
A thorough evauaton of the patent who presents for faca aesthetc surgery
shoud start wth ectaton of the patent's chef compant, and the examnaton
shoud be focused on that regon. Physca examnaton of the entre face shoud
note skn quaty as we as the presence of redundant skn on the neck, |ows, and
eyeds. Depth of the nasoaba fods and the presence of "maronette" nes on the
chn shoud be noted. Brow poston shoud be evauated, aong wth the dstance
from brow to harne. Bugng fat n the ower eyed regon and the presence of a
"tear trough" deformty, or deep fod at the d-cheek |uncton, shoud be evauated.
Faca fat atrophy and descent, a hamark of faca agng, shoud be noted.

Bleparoplasty and Bro!li#t
Excess skn and adpose deposts of the upper eyed are approached through an
ncson based on the supratarsa crease. Carefu attenton to markng w avod
the compcaton of overresecton. A strp of orbcuars musce s often excsed to
accentuate the supratarsa fod. Fat deep to the orbta septum s resected
seectvey. In the ower d, excess skn s removed through a subcary ncson.
Lower eyed fat may be ether excsed or repostoned. Compcatons can ncude
hematoma, ower d retracton, and n|ury to ocuar musces. If a hematoma forms
n the retro-orbta regon, a true surgca emergency exsts. Permanent vson oss
can occur f t s not mmedatey decompressed. Brow ptoss, |udged reatve to the
superor orbta rm, can be corrected through a number of ncsons (Fg. 45-53).75
Fg. 45-53.

Incsons for browft. $, Tempora scap ncson; !, tempora harne ncson; C,
mdne scap ncson; D, md-harne ncson; 5, drect eyebrow ncson; 1, drect
forehead ncson.

0aceli#t
Correcton of |ows, nasoaba fods, and redundant neck skn can be accompshed
wth a faceft procedure that both removes skn and tghtens the superca
muscuoaponeurotc system (SMAS) ayer. The SMAS es deep to the subcutaneous
tssue and contans the musces of faca expresson. The faca nerves are n a
pane |ust deep to the SMAS. The SMAS can be smpy pcated or a porton of t
excsed and cosed. A sub-SMAS dssecton technque can hep to eevate and
deveop ths ayer n separate fashon, wth care beng taken to avod n|ury to the
underyng faca nerves. The ncsons for most faceft technques are preaurcuar
wth extenson nto the tempora harne superory and nto the retroaurcuar
regon posterory and nferory (Fgs. 45-54, 45-55). The patysma ayer s
contnuous wth the SMAS ayer and can be pcated through a sma neck ncson
to emnate the appearance of vertca bands aong the musce edge. The most
common faceft compcaton s hematoma, whch may requre operatve dranage
to prevent skn ap necross. In|ury to faca nerves, most often tempora branch
and margna mandbuar branch, s seen n approxmatey 1% of cases.76
Fg. 45-54.

Incsons for cervcofaca
rhytdectomy.

Fg. 45-55.

Faceft. 12 Preoperatve appearance. B2 Postoperatve
appearance.

4inoplasty
The key to understandng rhnopasty s apprecatng the compex nasa anatomy
(Fg. 45-56) and the way n whch aterng ths framework w mpact the
appearance of the nose. Evauaton of the rhnopasty patent not ony shoud
ncude the aesthetc compants, but aso shoud consder the functon of the nasa
arways. Nasa arway obstructon can occur from severa structura probems. A
devated septum can severey mpede arow, as can probems wth the nterna
nasa vave. Obstructon at the nterna nasa vave, whch s the |uncton of the
upper atera cartage and septum, can be dented by appyng atera tracton on
the cheek skn to open the vave and observng whether arow mproves (Cotte
sgn). Arway obstructon can be addressed surgcay at the tme of rhnopasty.
Aesthetc deformtes of the dorsum of the nose are treated by a combnaton of
osteotomes, whch serve to reposton the nasa bones, and raspng of the bone.
Aesthetc deformtes of the tp of the nose are treated by reducng the wdth of the
ower atera cartages and/or sewng the cartages together to reduce tp wdth.
Sma tps can be augmented wth cartage grafts harvested from septum or
aurce (Fg. 45-57). Compcatons of rhnopasty ncude nducton of new nasa
arway obstructon and a varety of aesthetc deformtes.77
Fg. 45-56.

Rhnopasty
anatomy.

Fg. 45-57.

Rhnopasty. 12 Preoperatve appearance. B2 Postoperatve
appearance.

Suction Lipecto%y
Lposucton nvoves the remova of adpose tssue through mnma ncsons usng
a hoow sucton cannua. Athough the scarrng s qute nnocuous, a key prncpe
of posucton s that fat s beng removed wthout skn tghtenng. Therefore, one
rees on the patent's nherent skn eastcty to provde retracton over the treated
adpose depot. Assessment of skn tone s a vta part of the patent evauaton. If
there s skn axty n the area to be treated, t may worsen after posucton.
Importanty, posucton shoud be used as a too for contourng promnent adpose
depots and s not consdered a weght oss treatment. The best canddates for
posucton are ndvduas who are cose to ther goa weght and have foca
adpose deposts that are resstant to det and exercse (Fg. 45-58). The sucton
cannua removes fat by avusng sma parces of adpose tssue nto sma hoes at
the cannua tp. Wth standard sucton pectomy, fat s removed ony when the
cannua s actvey moved through the tssue panes. Mnma tssue ehects are
seen when the cannua s statonary. In genera, arger-dameter cannuas remove
adpose tssue at a faster rate but carry a hgher rsk of causng contour
rreguartes such as groovng and uneven remova of fat. Newer posucton
technoogy uses an utrasonc probe to emusfy the fat va cavtaton before
sucton. Advocates of utrasonc posucton report that the technque provdes a
more even and unform remova of adpose tssue. Recognzng that no one
technque s best for a patents and a anatomc regons, many surgeons use
utrasonc energy seectvey.
Fg. 45-58.

1 and B2 Preoperatve photos of a 22-year-od woman wth foca adpose deposts on
the trunk and extremtes. $2 Patent 3 months after surgery.

A ma|or advance n the ed of posucton was the deveopment of tumescent oca
anesthesa. Ths method nvoves the ntraton of very dute docane and
epnephrne (docane 0.05% and epnephrne 1:1,000,000) n arge voumes
throughout the subcutaneous tssues. Tumescent voumes may range from one to
three tmes the antcpated asprate voume. The dute docane provdes sumcent
anesthesa to aow the posucton to be performed wthout addtona agents,
athough many surgeons prefer to use sedaton or even genera anesthetc when
arge voumes of fat are to be removed. When genera anesthesa s used, the
docane dose may be reduced or even emnated. Wth tumescent anesthesa, the
absorpton of the dute docane from the subcutaneous tssue s very sow, wth
peak pasma concentratons occurrng approxmatey 10 hours after the
procedure.78 Therefore, the standard docane dosng mt of 7 mg/kg may be
safey exceeded. Current recommendatons suggest a mt of 35 mg/kg of docane
wth tumescent anesthesa.79 A very mportant component of the tumescent
anesthetc souton s the dute epnephrne, whch mts bood oss durng the
procedure.

Safety ssues are paramount for posucton because of potenta ud shfts
postoperatvey and hypotherma. If S5000 mL of asprate s to be removed, the
procedure shoud be performed n an accredted acute care hospta facty. After
the procedure, vta sgns and urnary output shoud be montored overnght n an
approprate facty by quaed and competent stah who are famar wth
peroperatve care of the posucton patent.79

38cisional Body $ontouring
When sgncant skn axty s present, mprovement n contour can be acheved
ony through skn excson. Therefore, a body-contourng surgery represents a
trade of excess skn for scar, and ths must be emphaszed durng patent
consutaton. The patent wng to accept scars n exchange for mproved contour
s key to be satsed wth the procedures. Wth the ncreased number of baratrc
surgery procedures over the past decade, body-contourng surgery has become
very popuar and s emergng as a new subspecaty of pastc surgery.

1bdo%inoplastyBPanniculecto%y
Abdomnopasty/panncuectomy s the most common body-contourng procedure
and can range from a mted-ncson skn remova n the ower abdomen to a
ma|or skn excson wth transposton of the umbcus and pacaton of the rectus
musces to further enhance contour.80 Some patents may benet from a
concurrent vertca ncson to remove skn n two vectors (Fg. 45-59). Possbe
compcatons ncude skn necross, persstent paresthesas of the abdomna wa,
seroma, and wound separaton. Necross of the umbcus may compcate
preservaton of that structure f the stak s excessvey ong or an umbca herna
s repared. Addng a vertca resecton ncreases the ncdence of skn necross,
especay at the conuence of scars n the ower abdomen.
Fg. 45-59.

12 Preoperatve photo of 35-year-od woman after gastrc bypass and massve
weght oss. B2 Patent 12 months after a eur-de-s abdomnopasty.

Bracioplasty &1r% Li#t(
Brachopasty, or arm ft, eaves a vsbe ongtudna scar on the upper arm.
Therefore, t s reserved for patents wth excessve skn n that regon. The patent
wng to accept the scar can be happy wth the resuts. Compcatons ncude
dsta seroma and wound separaton. Paresthesas n the upper arm and forearm
may occur secondary to n|ury of sensory nerves passng through the resecton
area, athough ths rarey ahects functon. Scar contracture n the axa may mt
shouder excurson n rare cases and requre revson.

Tig and Buttock Li#t
Treatment of oose skn on the thghs and buttocks nvoves a spectrum of
operatons customzed to the ndvdua patent. The outer thghs can be fted at
the same tme that an abdomnopasty s performed wth one contnuous scar
aong the bet ne. The same scar can be contnued a the way around the back to
ft the buttocks as we. Ths combnaton of abdomnopasty, thgh ft, and buttock
ft s commony referred to as a circum,erential lo0er (ody li,t. The nner thghs
can be contoured by ftng the skn and pacng the ncsons aong the gron
crease. Frmy anchorng the deep thgh fasca to Coes' fasca s essenta to hep
prevent spreadng of the aba. In cases of severe excess skn on the nner thghs, a
ong vertca ncson s necessary. Compcatons of thgh and buttock ft ncude
seroma, wound separaton, skn necross, and change n the shape of the genta
regon (wth possbe sexua dysfuncton). Bood oss durng the procedure may
necesstate transfuson.

4eduction ,a%%aplasty
Breast reducton s performed to treat symptoms of macromasta, most commony
consstng of the trad of upper back pan, bra strap groovng, and rashes under the
fod of the breasts. Athough ths procedure has reconstructve ndcatons, the
aesthetc outcome s of consderabe mportance. Fundamenta to the success of
the procedure s the estabshment of symmetrc and proper nppe poston. Nppe
ptoss s graded by the nppe poston reatve to the nframammary fod (IMF).
Grade 1 ptoss descrbes a nppe 1 cm beow the IMF. Grade 2 ptoss descrbes a
nppe 1 to 3 cm beow the IMF. Grade 3 ptoss descrbes a nppe poston >3 cm
beow the IMF. Pseudoptosis or (ottoming out s a term used to descrbe the
descent of the breast tssue beow the nppe and s a potenta ong-term
compcaton of breast reducton. In addton to casscaton of nppe ptoss, a
thorough preoperatve evauaton aso ncudes measurement of the dstance from
sterna notch to nppe bateray, as we as measurement of the dstance from
nppe to IMF. The base wdth of the breast shoud aso be consdered. Many
patents are found to have sgncant basene asymmetres n these
measurements. Preoperatve breast cancer screenng consstent wth current
Amercan Cancer Socety gudenes shoud be performed for a patents
undergong eectve breast reshapng surgery. The panned new nppe poston
shoud be symmetrca at the IMF aong the breast merdan. There are many
technca varatons of the breast reducton procedure, but neary a of them have
common eements of reshapng the skn enveope n three dmensons and movng
the nppe to a new ocaton on a vascuarzed tssue pedce. The pedce s de-
eptheazed to preserve the subderma vascuar pexus. Fgure 45-60 shows the
cassc "keyhoe" Wse pattern reducton technque. The skn resecton s desgned
to create a conca shape, and the nppe s transposed on an nferory based
pedce.81 Ths resuts n an nverted T-shaped scar. Fgure 45-61 shows a patent
treated usng ths technque. A breast reducton technques keep the scars on the
ower haf of the breast so they are covered by cothng. Technques have been
desgned to mnmze scar ength and even emnate the horzonta component n
the IMF. Fgure 45-62 depcts a vertca scar skn resecton pattern wth the nppe
preserved on a superor pedce.82,83 For excessvey arge breasts, the requred
pedce ength may be too ong to provde adequate bood suppy to the nppe. In
such cases, the nppe s removed and repaced onto a vabe tssue bed as a fu-
thckness skn graft. Compcatons of breast reducton ncude decreased nppe
sensaton, nppe oss (rare), skn necross, hematoma, and fat necross. Ths ast
compcaton can resut n a rm mass of scar wthn the breast that may need
carefu evauaton and foow-up to dstngush t from a neopastc mass. Long-term
compcatons ncude nabty to breastfeed and pseudoptoss, as mentoned
earer.
Fg. 45-60.

Inferor pedce reducton mammapasty. 12 Markngs for Wse pattern reducton. B2
Purpe area s regon to be de-eptheazed. $2 Dark bue regon s area to be
resected. A segment of the nferor pedce s de-eptheazed. The nferor pedce s
dssected straght down to the chest wa, wth mantenance of an 8- to 10-cm
pedce wdth. Latera and meda segments are resected. After ths s accompshed,
the superor ap s dssected to the cavce. Breast subcutaneous tssue and
parenchyma are resected from the superor poe. The vertca mbs are brought
together and to the merdan of the nframammary fod. The nppe s then set n ts
new superor poston. /2 T-shaped ncson on na cosure.

Fg. 45-61.

1 and B2 Preoperatve photos of a 25-year-od woman wth symptoms of upper back
pan, bra strap groovng, and rashes under the fods of her breasts treated wth a
Wse pattern nferor pedce reducton. $ and /2 Patent 6 months after surgery.

Fg. 45-62.

Vertca reducton mammapasty, Le|our technque. 12 Markngs for vertca
reducton. B2 Purpe area s regon to be de-eptheazed. $2 Dark bue regon
represents nferor poe to be resected. The shaded regons are the atera and
meda segments that are to be undermned; these areas can aso be posuctoned.
The superor pedce s de-eptheazed and dssected to the chest wa. The tssue
and parenchyma from the nferor poe are resected. The pars from the atera and
meda segments are sewn together. The nppe s transposed on ts pedce to ts
new poston. /2 Cosure of the vertca mammapasty. There s bunchng up of skn
and tssue aong the vertca mb that w resove over tme; n addton, the new
nframammary fod w decare tsef superor to the orgna one.

,astope8y
In contradstncton to breast reducton, n whch patents are treated for symptoms
reated to heavy breasts, mastopexy s a three-dmensona reshapng of the breast
performed wth no or mnma voume remova. The prncpes are the same,
however: The skn enveope s contoured and the nppe ocaton optmzed.
Because the degree of ptoss may be ess severe than n breast reducton cases,
the patterns of skn resecton can vary wdey. Mnma patterns may nvove
excson of |ust a crescent of skn from above the areoa or a perareoar ("donut")
resecton. The Wse keyhoe pattern can be used for arger skn excsons.

1ug%entation ,a%%aplasty
Athough the use of prosthetc mpants can successfuy ncrease breast sze, the
surgeon must fuy understand both the rsks of the bomateras and the way n
whch a specc mpant of gven shape and sze can be surgcay ntegrated nto
the exstng breast mound to acheve the desred resut.84 To address the atter
pont, the surgeon must rst consder the possbe surgca approaches for mpant
pacement. The three commony used ncsons for pacement of cosmetc breast
mpants are nframammary, perareoar, and axary (Fg. 45-63).85 A
transumbca breast augmentaton technque has been advocated by some
surgeons more recenty, but crtcs of ths approach pont out that there s poor
contro over the dssecton of the mpant pocket and that drect access to the
tssues of the breast s nadequate to contro beedng vesses. In addton, ony
sane mpants can be used wth transumbca breast augmentaton because the
preed scone mpants are too arge to pass through the ncson and narrow
tunne. The mpants may be paced n a subganduar or subpectora poston (Fg.
45-64). Many surgeons prefer the subpectora pacement because t provdes
greater soft tssue coverage n the upper poe of the breast and can hde contour
rreguartes reated to the mpant. Ths soft tssue coverage s especay
mportant wth sane mpants, because vsbe rppng can occur. The next ssue
to consder s exstng nppe poston. If a patent has md ptoss, the sheer voume
of the mpant may rase the nppe to an acceptabe eve. For more severe ptoss,
a concurrent mastopexy s necessary. Some surgeons advocate performng the
mastopexy as a second stage after the mpant has setted nto poston.
Fg. 45-63.

Incsons for augmentaton mammapasty. $, Inframammary; !,
axary; C, perareoar.

Fg. 45-64.

Pacement of breast mpant. 12 Subganduar. B2
Subpectora.

Potenta compcatons reated to the mpant tsef are numerous, and the patent
must be fuy nformed of these possbtes before undergong surgery. One
mportant pont s that there s a hgh kehood that the patent w requre a
second operaton to address an mpant probem. The mpant compcatons are
essentay a oca. Athough there was concern n the past that mpants mght be
assocated wth systemc connectve tssue dsorders, arge epdemoogc studes
have not supported such a nk. The fears over mpant safety were so strong that
the Food and Drug Admnstraton (FDA) decared a moratorum on the use of
scone ge mpants n 1992. At that tme, sane-ed mpants were st aowed
for genera cosmetc use. Data were comped on scone ge mpants, and these
devces were approved by the FDA for genera use n 2006.86 Potenta mpant
compcatons ncude rupture of the devce. For sane mpants, ths resuts n
rapd deaton. For scone ge mpants, the rupture may be not be obvous and
can be conrmed by MRI. Another compcaton s capsuar contracture, whch
resuts n a tght enveope of scar that can dstort the shape of the mpant and
cause pan n severe cases. A compcaton more common to sane devces s the
appearance of rppng n the upper poe of the devce. Impant maposton can
aso dstort the breast shape and requre reoperaton. Safety data prnted on the
omca FDA-approved package nsert from one of the devce manufacturers show
the ncdence of reoperaton to be 29.9% over 7 years n a study of 901 women
undergong prmary breast augmentaton wth sane-ed mpants (postapprova
study). The rate of severe capsuar contracture (grade 3 or 4 on a 4-pont scae)
was 15.7%, and the rate of mpant rupture was 9.8%.87 For scone ge-ed
mpants, the reoperaton rate was observed to be 23.5% over 4 years n a study of
455 women undergong prmary breast augmentaton. The rate of severe capsuar
contracture (grade 3 or 4 on a 4-pont scae) was 13.2%, and the rate of mpant
rupture (evauated by MRI) was 2.7%. The three most common reasons for
operaton, n order, were capsuar contracture (28.9%), mpant maposton
(15.6%), and ptoss (14.1%). For secondary augmentaton, compcaton rates were
much hgher, wth the reoperaton rate over 4 years rsng to 35.2%. The rate of
capsuar contracture was 17.0%, and the rate of mpant rupture was 4.0%.88

Another concern regardng breast mpants s the ssue of whether adequate
mammography can be performed after augmentaton. Dspacement technques
can be used by the mammographer to vew the breast tssue. Athough patents
are advsed that mpants may ahect mammography, a study surveyng women
who dd and dd not undergo breast augmentaton found no statstca dherence n
survva or detecton of carcnoma between the two cohorts.89

Gyneco%astia
Mae breast excess or gynecomasta can be caused by a host of medca dseases
and pharmacoogc agents. Medca condtons assocated wth gynecomasta
ncude ver dysfuncton, endocrne abnormates, Knefeter's syndrome, rena
dsease, testcuar tumors, adrena or ptutary adenomas, secretng ung
carcnomas, and mae breast cancer. Causatve pharmacoogc agents ncude
mar|uana, dgoxn, spronoactone, cmetdne, theophyne, dazepam, and
reserpne. Athough these numerous causes must be consdered, a ma|orty of
patents present wth ether dopathc enargement of the breast parenchyma
(more common n teenagers) or smpe skn ptoss and excess adpose deposts on
the chest wa (consdered pseudogynecomasta; more common n adut maes). To
obtan a at chest, both posucton and/or skn excson technques can be used.90

Pastc Surgery
Monday, October 11, 2010
2:00 PM
"rened" genera surgery
Webster's denton
Schwartz Denton

Prncpes
1. Doctor-Patent reatonshp s based on INTEGRITY, as n any other
surgca dscpne.
2. Eectve surgery means that the patent "eects" to undergo surgery.
Preoperatve preparaton s absoutey necessary.
3. The surgeon must wegh the benets of the surgery aganst the
possbe rsks.
Ceft paate operaton above 15 yo s not done due to hgher rsks than
benets
At the nta consutaton, the surgeon must dene the deformty and
recognze the "true" versus the "apparent" defect.
Team approach
The concept of a group of cncans from a varety of dscpnes
workng on a probem yeds the optma care for compex probems.
6. In preoperatve pannng, the pastc surgeon must consder the use of
a "reconstructve adder"

Free tssue transfer <- regona tssue transfer <- oca tssue transfer <-
skn graft <- drect tssue cosure <- aow wound to hea by secondary
ntenton

7. The pastc surgeon must avod overaggressve surgery. The prncpe
of "ess s more" partcuary appes to pannng cosmetc procedures.
8. Repace ke wth ke.
9. In faca reconstructon, surgery must repace the mssng part or parts.
10. In genera, the nvoved aesthetc unt or subunt must be
reconstructed.
11. Autogenous reconstructon s generay preferabe to aopastc
reconstructon.
12. When resurfacng compex defects, the reconstructve ap must the
defect three dmensonay.
13. The tmng of the surgca nterventon can be probematc and shoud
aways be carefuy consdered.

Requstes for successfu pastc surgery
1. Sense of form
Acceptabe proportons of human form
Exstng cutura standards
LEONARDO da VINCI's "dvne proportons"
2. Good aesthetc |udgment
Anthropometry
Anatomca proportons
Prevang standards
What s beauty?
Beauty of face
Beauty of gure
Stye and fashon
Cutura Standards
Ethnc dherences
3. Abty to vsuaze resuts/Abty to magne eventua resuts

Preoperatve pannng s vauabe
Tranng n pastc surgery
Gen surg - 4 yrs
Pastc surg - 3 yrs

Success in plastic surgery is a %atter o# balance bet!een beauty and
blood supply2

Success n the psychoogca .



Reconstructon
Monday, October 11, 2010
2:59 PM
Basc prncpes and cnca appcatons

Wound Defects
Dherent sze shape severty

Genera Prncpes
Use the smpest form of reconstructon possbe

Goas of reconstructon
To provde vabe coverage
To restore form, contour, functon, and coor

Basc Prncpe
Method or manner of reconstructon w depend on the nature, ocaton,
extent, and specc requrements of any gven defect

Leves of thckness of n|ures
Norma
Superca
Superca parta thckness
Deep parta thckness
Fu thckness

Smpe/cutaneous parta thckness
Superca parta thckness
Deep Parta thckness

Casscaton of Defects
Fu-thckness
Wthout tssue oss
Wth tssue oss

Skn Graft (Schwartz)
Types
Spt thckness Skn Graft
1. Thn .008-.012 nch
2. Medum .013-.016 nch
3. Thck .017-.020

STSG vs FTSG
Thckness <.020 nch >.020 nch
Donor stes Wde areas Lmted
Harvest Dermatome Surgca bade
Revascuarzat
on
Easy Dmcut
Cosmetc
resuts
Inferor superor

Indcatons for FTSG
Coverage of ower eyed defects
Resurfacng defects over the face and voar aspect of the hands

Cnca evauaton of wound for coverage
Granuaton tssue ne, vevety, no foregn bodes

Cnca assessment for coverage

Evauaton of wound nfecton
Ouanttatve bacteroogy
Punch bopsy over a rapd sde technque

Cnca evauaton of wound

Preparaton of wound cosure
* do not cose an nfected wound

Loca Wound Care
Sane souton (NSS) s the ony safe souton for washng n|ured tssues

Topca Antbacteras
Sver ntrate 0.5% - freshy prepared by the pharmacy
Sver sufadazne 11% (ammazne)
Sver sufadazne + cerum ntrate (ammacerum)

Topca antbacteras
Mafende acetate (mafyon)
Pvdone odne (deays wound heang) vs cadoxmer odne (does not deay
wound heang)
Gentamycn (garamycn)
Furasn

A topcas except 0.5% sver ntrate w deay eptheazaton

Preparaton for Wound cosure
Systemc Evauaton
Lab exams: tota proten, cbc

Dressng materas
64 ayers of OS to prevent bactera from reachng the surface of the owund

Gauze
Put new generaton gauze then the OS and then the net

Wound dressngs
Boogc
Amnon - from pacenta of CS patents
Cadaver skn -
Porcne skn - pork skn (amost the same w/ human skn except for
the eve of fat

* boogc not use to prevent transmssbe dseases ke HBV

New generaton dressng
Poyurethane dressngs
Eg opste, Tegaderm
Hydroges
Hydroceods
Hydroceuar dressngs
Agnates
Nanocrysta Sver Dressngs
Cadexomer
Duoderm
Katostat - soft ke cotton, stcks to the surface better, not panfu when
removed
Aquace Ag
Mesh top Dressng

Skn Substtutes
Cutured autoogous ces (cutured epthea autographs)
Epce - taken from ces manufactured w/ the use of prepucea (from
prepuce) ces
Integra derma regeneraton Tempate
Dermagraft TC

Harvestng STSGs

Care of Recpent Ste
Te-over bous dressngs
Proper mmobzaton usng mods and spnts
Cosed dressngs
No openng for 5-10 days except sgns

Requstes for Successfu STSG

Care of the STSG Donor Ste
Put katostat then gauze and then eastc bandage. Do not open for 1 wk.

Compcatons of Skn Graftng
Seroma formaton - 60% of faures of skn graftng
Beedng
Infecton
Contour and coor defects